Kings 2017 (Jan) Flashcards
A man has SOB at rest, which gets worse with exertion. He denies having palpitations but feels his heart is going fast. Based on his symptoms and the ECG below, what is the diagnosis?
atrial flutter
AVNRT
junctional tachy
sinus tachy
ventricular tachy
Atrial Flutter
A patient comes to clinic with T2DM and PAD. What is the single most effective way to reduce the risk of gangrene?
start human insulin
arterial transplant
education about foot care
educational about foot care
61 yo man, 2 months ankle swelling. 30 year history seronegative polyarthritis and has hypertension. On sulfasalazine, hydrochloride something? and one other drug.
Pitting oedema up to calves. Some joint swelling.
bloods:
high CRP
low albumin
high urine protein:creatinine ratio
Urine dip: positive for protein. No nitrates or leukocyte.
BP: 117/70Renal biopsy is organised.
what would be seen on biopsy?
A. follicular segmental necrotising glomeruloscelrosis
B. interstitial inflammation
C. renal amyloidosis
D. no change
renal amyloidosis
Causes of nephrotic syndrome
Secondary to systemic disease:
- DM: glomerulonephrosclerosis
- SLE: membranous
- Amyloidosis: which is seen in all conditions causes chronic inflammation
FSGS:
- Commoner in Afro-Caribs
- Idiopathic or Secondary: VUR, Berger’s, SCD, HIV
- Biopsy: focal scarring, IgM deposition
- Rx: steroids or cyclophosphamide/ciclosporin
- Prog: 30-50% → ESRF (may recur in transplants)
Membranous nephropathy:
- 20-30% of adult nephrotic syndrome
- Associations
- Ca: lung, colon, breast
- AI: SLE, thyroid disease
- Infections: HBV
- Drugs: Penicillamine, gold
- Biopsy: subepithelial immune complex deposits
- Rx: immunosuppression if renal function declines
- Prog: 40% spontaneous remission
Minimal change (children)
Memransoproliferative (rare)
59 year old woman presents with weight gain, tiredness, cold intolerance…
blood results:
tsh high/N
t4 slightly low
cortisol normal
thyroid peroxidase antibodies elevated
A. toxic multinodular goitre
B. primary hypothyroidism
C. central thyroiditis (pituitary tumour)
D. Graves’ disease
primary hypothyroidism
Child with hip pain, fever, difficulty walking and cannot weight bear. Blood results show raised WCC, and raised CRP. What is the most likely diagnosis?
- Transient synovitis
- Reactive arthritis
- Septic arthritis
- Juvenile arthritis
Answer: primary hypothyroidism – presents with high TSH and low T4 and thyroid peroxidase antibodies elevated which points to Hashimotos (type of primary hyperthyroidism). Toxic multinodular goitre and graves disease would cause hyperthyroidism and pituitary tumour would cause low TSH and low T3/T4
Septic arthritis
65 y/o man. Has had pain in right leg when walking certain distance. Right calf is now painful and swollen. O/E pulses are felt in left leg, but no pulses can be felt below the femoral level of right leg. Right foot is pale and cold. What is the diagnosis?
- Saddle embolus
- DVT
- Iliac artery embolus
- Superficial femoral artery embolus
Superficial femoral artery embolus
73 y/o gentleman presents to A and E with confusion and trouble speaking (i think). Is known alcoholic. Had a fall at home 10 days ago. What is the most likely diagnosis?
- Extradural hemorrhage
- Subdural haematoma
- Wernicke’s encephalopathy
Subdural haematoma
Man, fever, bruising? Bloods: Increased APTT, Prothrombin Time, D Dimer.
- Christmas disease
- DIC
- Haemophilia Disease
Answer: DIC
Typical presentation, think patient was septic in this question. Results also are typical of a DIC.
A healthy 46 year old gentleman undergoes a routine vasectomy, an hour after the procedure he develops a temperature of 40.5C, BP: 80/50. His muscles become stiff.
A. Acute MI
B. Allergy to muscle relaxant
C. Myotonic
D. Malignante hyperthermia
E. Porphyria
Malignant hyperthermia
Overview
- condition often seen following administration of anaesthetic agents
- characterised by hyperpyrexia and muscle rigidity
- cause by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle
- associated with defects in a gene on chromosome 19 encoding the ryanodine receptor, which controls Ca2+ release from the sarcoplasmic reticulum
- neuroleptic malignant syndrome may have a similar aetiology
Causative agents
- halothane
- suxamethonium
- other drugs: antipsychotics (neuroleptic malignant syndrome)
Investigations
- CK raised
- contracture tests with halothane and caffeine
Management: dantrolene - prevents Ca2+ release from the sarcoplasmic reticulum
- A 42 year old gentleman attends the A&E department vomiting blood and he is taken in for an urgent endoscopy. On endoscopy there is an ulcerated lesion in the second part of the duodenum. Which artery?
A.
B. Celiac Trunk
C. Gastroduodenal A
D. Hepatic Artery
E. Superior mesenteric A
Gastroduodenal A: is bleeding
SMA supplies distal duo from second part of duodenum
10 year old boy with sore throat and fever. On examination the pharynx appeared red and tonsils swollen.
Mum wants abx which symptoms would allow abx to be prescribed.
1) sore throat and coryzal symptoms
2) pyrexial, tender lymph nodes and no cough
3) apyrexial, tender lymph nodes and no cough
4) apyrexial, tender lymph nodes and no cough
pyrexial, tender lymph nodes and no cough
80 yo COPD suffer with Ankle oedema on Salmeterol, Beclametasone, tiotropium has breathlessness and has had 4 admissions in the past few months with no improvement. Has regular carers visiting her. Best next step for breathlessness?
Home Oxygen
IV Fentanyl
IV Morphine
Nebulised Salbutamol
Something else
Home Oxygen
Assess patients if any of the following:
- very severe airflow obstruction (FEV1 < 30% predicted). Assessment should be ‘considered’ for patients with severe airflow obstruction (FEV1 30-49% predicted)
- cyanosis
- polycythaemia
- peripheral oedema
- raised jugular venous pressure
- oxygen saturations less than or equal to 92% on room air
Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
- secondary polycythaemia
- nocturnal hypoxaemia
- peripheral oedema
- pulmonary hypertension
28 yo female who’s 22 week pregnant has PE (?or DVT). What is the treatment?
Sub Cut LMWH
Sub Cut Unfractionated Heparin
Oral Warfarin
Oral Bivilarudin
Something else
Sub Cut LMWH
49yo woman with schizophrenia, scheduled for a routine inguinal hernia operation. On the morning of the operation, she does not give her consent. She is able to understand the information given and the consequences. She is currently on antipsychotic medication and has no active symptoms. What is best next step?
- Call psychiatrist
- Discharge and call General Practitioner
- Proceed with the operation
- Increase dose of antipsychotic medication
- Do not discharge under the Mental Health Act
Discharge and call General Practitioner
80~ yo woman with a history of recent falls. A hip fracture is suspected, brought in and scan demonstrated displaced intracapsular fracture of the neck of femur. What treatment is indicated?
- Compression
- Brace & Mobilise
- Dynamic Hip Screw
- Femoral Nail
- Hemiarthroplasty
Hemiarthroplasty
An 80 year old female presents with a red, swollen leg. She has been feeling unwell and nauseous over the past week. She has also lost her appetite. She has a past medical history of hypertension, T2DM, vitamin B12 deficiency.
Obs:
BP: 92/50, HR: 120, sats 92% on air, glucose 18 mmol/L
What is the most likely cause of her hypotension?
- Autonomic neuropathy
- Hyperosmolar hyperglycemic state
- Pulmonary embolism
- Sepsis
- Silent MI
Sepsis
A 45 year old male presents with a sixth month history of increasing dragging of his right leg. His wife said that his right hand sometimes shakes. On examination there was some stiffness in the right leg, but power and reflexes were normal. Right foot tapping was weak.
What is the most likely diagnosis?
- Huntington’s disease
- Left cerebral hemisphere tumour
- Multiple sclerosis
- Multisystem atrophy
- Parkinson’s disease
Left Cerebral hemisphere tumour
Huntington’s disease is an inherited neurodegenerative condition. It is a progressive and incurable condition that typically results in death 20 years after the initial symptoms develop.
Genetics
- autosomal dominant
- trinucleotide repeat disorder: repeat expansion of CAG
- results in degeneration of cholinergic and GABAergic neurons in the striatum of the basal ganglia
- due to defect in huntingtin gene on chromosome 4
Features typical develop after 35 years of age
- chorea
- personality changes (e.g. irritability, apathy, depression) and intellectual impairment
- dystonia
- saccadic eye movements
2 month baby- bronchiolitis-resus at home, brought to ed, cxr shows posterior healing rib fractures of 3,4,5, what is cause of fractures?
Birth trauma
resus injury
Non Accidental injury
Non -accidental injury
Birth trauma would probably have been picked up at birth and it’s not typical to have rib fractures. He stopped breathing and was resuscitated but the ribs would not be healing as this happened within hours.
45yo man who had left diverticular disease, left hemicolectomy , started vomiting, 400mls of billous vomit, nil bowel opening, axr showed dilated small bowel loops-whats first action
NG tube
CT abdo
Barium enema
NG tube
70 year old woman with new dx t2dm with polyuria poly dips iA, with a BMI of 35. Drinker 2-3 units of alcohol a week and is a non smoker. She stopped exercising since her dog died 2 years ago. What’s the most important part of patient education?
a) Importance of regular exercise
B) Switching to a high fibre diet
C) Blood glucose monitoring and symptoms of hypos
D) Decrease salt intake
Importance of regular exercise
50 year old man presents to neurology clinic complaining of difficulty walking. Diabetic? Was initially able to walk so far but now has reduced. On examination, calves are slightly wasted. Globe and stocking distribution tingling sensation with decreased proprioception, absent reflexes, and depressed plantar response. 20 units alcohol a week.
a) vitamine B12 deficiency
B) Diabetes?
vitamine B12 deficiency
SACD symptoms
Lady wants to renew prescription for Orlistat despite no weight loss in 6 months. She smokes, no alcohol, no exercise. Guidelines state if no weight loss with Orlistat in 12 weeks, change medication. What do you tell her?
A). Renew her prescription and review after 3 months
B). Refuse to renew and try to find out about her lifestyle and make appropriate changes
C). Renew her prescription only if she agrees to make lifestyle changes
D). Refer for bariatric surgery as she has exhausted all non-surgical management
E). Refuse to prescribe as she doesn’t meet the guidelines
Refuse to renew and try to find out about her lifestyle and make appropriate changes
120 mg up to 3 times a day, dose to be taken immediately before, during, or up to 1 hour after each main meal, continue treatment beyond 12 weeks only if weight loss since start of treatment exceeds 5% (target for initial weight loss may be lower in patients with type 2 diabetes), if a meal is missed or contains no fat, the dose of orlistat should be omitted.
Man has left red swollen cheek and pain and bleeding from left nostril. He can’t tolerate nasal endoscopy. What investigation would you do next
A). CT head
B). X-ray skull
C). Intranasal steroids
D). Sinus washout
E). Antibiotics
CT Head
Squamous cell carcinoma of the nasopharynx
- Rare in most parts of the world, apart from individuals from Southern China
- Associated with Epstein Barr virus infection
- PC:
- Systemic symptoms: Cervical lymphadenopathy
- Nasal:
- Otalgia
- Unilateral serous otitis media
- Nasal obstruction, discharge and/ or epistaxis
- Cranial nerve palsies e.g. III-V
- Investigation:
- Imaging: Combined CT and MRI.
- Treatment
- Radiotherapy is first line therapy.
Female, 2 month history of abdo pain/discomfort, weight loss, no blood or mucus in stool.
Results:
Normocytic Anaemia
Low folate
- Coeliac
- IBS
- Ulcerative Collitis
Coeliac
Female, acute upper abdo pain radiating to the back, on a background of two years of intermittent RUQ pain.
Results: high amylase I think
Which of the following is most likely to be a factor:
- Pituitary adenoma
- Hyperlipidaemia
- Gallstones
Gallstones
8 year old boy fell from tree had displaced closed fracture suprcondylar what structure most likely to get damaged. (/most likely complication?)
- Brachial artery
- Radial nerve
- Biceps
- Compartment syndrome
- Avascular necrosis is the capitulum
Compartment synbdrome:
- This is a particular complication that may occur following fractures (or following ischaemia re-perfusion injury in vascular patients). It is characterised by raised pressure within a closed anatomical space.
- The raised pressure within the compartment will eventually compromise tissue perfusion resulting in necrosis. The two main fractures carrying this complication include supracondylar fractures and tibial shaft injuries
Symptoms and signs
- Pain, especially on movement (even passive)
- Parasthesiae
- Pallor may be present
- Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
- Paralysis of the muscle group may occur
Diagnosis
- Is made by measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic.
Treatment
- This is essentially prompt and extensive fasciotomies
- In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
- Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
- Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered
- Death of muscle groups may occur within 4-6 hours
A 7 year old boy presents to his GP surgery with his mother after having suffered from two/recurrent episodes of right ear pain, hearing loss and discharge from the right ear. Between these episodes he is completely well. What is the most likely diagnosis?
- Acoustic Neuroma
- Cholesteatoma
- Otitis Externa
- Otitis Media
- Mastoiditis
Otitis Media
