Transcript Revision Exam Term 1 2015 feedback 9 July

MCQ Revision Term 1
2015
1.
A 24 year old motor bike rider is involved in an accident while riding his bike. He is
bought by ambulance to the Emergency Department where you make a diagnosis
of a fracture through the midshaft of his left tibia based on the clinical findings.
Which one of the following is the MOST important feature of your initial
management of this young man?
A. Ensure that his wounds are cleaned
B. Ensure that appropriate X rays are performed
C. Ensure that he receives adequate analgesia
D. Ensure that you perform a neurovascular examination of his left leg
E. Ensure that the orthopaedic surgery team is called
2.
A 69 year-old woman with post-polio syndrome since childhood, type 2 diabetes for 7
years (last HbA1C 8.8%), and hypertension for 10 years is seen in the clinic complaining of
burning feet exacerbated by warm weather and hot showers. She drinks 2 glasses of wine
per night. She has been on a very low calorie liquid diet and has lost 20 kg over 6 months.
She takes metformin, paracetamol, and hydrochlorothiazide.
On examination she is obese (BMI 32). Reflexes are absent at the ankles and vibration
sense is absent and light touch is diminished in the toes and feet.
The most likely cause of her symptoms is
A. Post-polio neuropathy
B. Medication Side Effect
C. Diabetic Neuropathy
D. Alcoholic Neuropathy
E. Vitamin B12 deficiency
3.
A 48 year old man is in the gymnasium, lifting weights. He experiences the
explosive onset of headache and neck pain and is seen shortly afterwards in the
Emergency Department. At this stage, he still complains of occipital headache,
but there is no evidence of neck stiffness or of any neurological deficit. He is
afebrile. A CT brain is normal.
Which one of the following is the most important next investigation?
A. Full blood examination
B. Lumbar puncture
C. No further investigation required
D. CT scan cervical spine
E. MRI brain
16.
A 62 year old woman presents to her general practitioner for routine review. She has type
2 diabetes and osteoarthritis. Her medications are metformin, glibenclamide, atorvastatin,
ibuprofen and aspirin.
Three months ago, her serum creatinine was normal and her HbA1c was 6.9. On this
occasion her serum creatinine is twice normal and her HbA1c is 7.2. Her BP is 130/85.
What therapy adjustment does she most need?
A. Add an ACE inhibitor.
B. Add insulin.
C. Stop aspirin.
D. Stop atorvastatin
E. Stop metformin
What is the diagnosis?
• A doubling of sCr 95 (eGFR > 60)  190
– IF IN STEADY STATE sCr (eGFR: 31)
– BUT PROBABLY NOT…therefore eGFR < 31 (maybe zero!)
• AKI
• much less likely accelerated CKD
• or spurious sCr elevation
• The usual causes of AKI
– Obstruction (post-renal)
– Renal hypoperfusion (pre-renal causes)
– Here iboprofen a likely culprit
– Parenchymal disease (“renal”)
• Vasculature
• Glomeruli
• Tubulo-interstitium
– Ibuprofen a possible cluprit
Metformin
•
MoA:
–
–
reduce hepatic glucose production (gluconeogenesis) enhancing actions of insulin and inhibiting actions of glucagon,
lesser effect to increase muscle and adipose uptake of insulin
•
Kinetics: excreted unmetabolised proximal tubules
•
•
•
AEs:
Chronic. GIT intolerance
Acutely: Lactic acidosis, Hypoglycaemia (co-contributor)
•
–
Almost always with second hit
–
Kinetic factors: AKI or unrecognised CKD, overt overdose
–
–
Factors that increase lactate production/ produce metabolic acidosis: shock or heart failure, liver disease, hypoxia, AKI/CKD, etc
Hypoglycaemia: other hypoglycaemic agents or liver failure, etc
eTG: Top dose 3g/daily (little benefit above 2g)
–
–
–
CrCl < 90mL/min: ≤ 2g
CrCl < 60mL/min: ≤ 1g
CrCl < 30mL/min: 0 g
•
•
You will see some permissiveness around these values.
Requires active patient counselling, assessment of risk:benefit, full consideration of alternatives.
Why do we stop
ACEi/ARBs and NSAIDs in AKI?
• “Nephrotoxins”?
Hypoperfusion
incl.
Volume depletion
Thus diuretics
ACEis
ARBs
Prevent
compensatory
vasocontriction
NSAIDs can also cause allergic reaction: acute interstital nephritis
42 wrong
18.
Twelve hours after a sub-total thyroidectomy for thyrotoxicosis, a 32 year old woman
becomes restless, cyanosed and develops a stridor.
Which one of the following is the MOST appropriate course of action?
A. Measurement of blood gases
B. Endotracheal intubation
C. Lung scan
D. Exploration of the wound
E. Indirect laryngoscopy
49 wrong
9.
Josh, a 27 year old injecting drug user, is admitted to hospital with fever and found to
have methicillin-susceptible Staph. aureus endocarditis. He gives a history of an
erythematous maculopapular rash with oral penicillin several years earlier.
Which one of the following antibiotics is the preferred antibiotic treatment in this
situation?
A. Intravenous erythromycin
B. Intravenous ceftriaxone
C. Intravenous cefazolin
D. Intravenous vancomycin
E. Intravenous flucloxacillin.
Category
Moderate-spectrum
Antiboitics
Cephalexin, cefalotin (cephalothin)
and cephazolin
Spectrum of activity *
Streptococci and staphylococci,
including beta-lactamase–producing staph.
nb some (MSSA) carry inducible enzymes that hydrolyse cephazolin
Poor or no activity
Enterococci and Listeria monocytogenes
MRSA
Gram-negative anaerobic organisms (including Bacteroides fragilis
- Escherichia coli and some Klebsiella species
Moderate-spectrum cephalosporins
with anti-Haemophilus activity
Cefuroxime and cefaclor
resp. tract infections cefuroxime cf cephalexin/ cefaclor:
superior pneumococcal activity.
Broad-spectrum cephalosporins
Cefotaxime and ceftriaxone
Majority of community-associated enteric Gram-negative rods
Less active against staphylococci than older cephalosporins
, and are inactive against MRSA
ESCAPPM organisms (Enterobacter, Serratia, Citrobacter freundii,
Aeromonas, some Proteus sp, Providencia, Morganella morganii)
Extended-spectrum beta-lactamase enzymes (ESBLs) produced by some
organisms (eg E. coli, Klebsiella pneumoniae, Enterobacter species)
Broad-spectrum
with antipseudomonal activity
Ceftazidime and cefepime
The majority of the enteric Gram-negative rods,
Both drugs are inactivated by ESBLs,
including Pseudomonas aeruginosa Ceftazidime may be inactivated by cephalosporinase enzymes
eTG complete, accessed July 2015
Antibiotic hypersensitivity
•
From eTG complete
– IgE mediated immediate hypersenitivity
•
Uticaria, angioedema, bronchospasm, anaphylaxis
–
Not beta-lactam again without desensitisation (or specialist advice re risk of cross reactivity)
– Delayed-type hypersensitivity
•
•
Macular, papular, morbiliform rash several days
T-cell mediated
–
•
May not be reproduced without concurrent infection
Exceptions (not for rechallenge)
–
–
–
Serum sickness
» Vasculitic rash, arthritis/ arthralgia, flu like symptoms, proteinuria, fever (DDx of PUO)
SJS/ TEN: sheet like skin and mucosal loss
DRESS: drug (desquamative) rash, (peripheral) eosinophilia, systemic (esp liver dysfunction) symptoms
– If penicillin (‘cillins, but others beware augmentin, tazocin, etc)
•
•
•
Non-penicillin beta lactam: cephalosporin, carbepenem, aztreonam
Non-beta-lactam
(Desensitisation)
eTG complete: accessed July 2015
39 wrong
50. Which one of the following statements about fine (as compared with course) crackles
on auscultation is true?
A. They are pathognomonic of idiopathic pulmonary fibrosis.
B.
They can change or disappear with coughing.
C.
They may be influenced by changes in body position.
D.
They occur most often during early inspiration.
E.
They tend to appear early during inspiration and throughout expiration
Fundamentals of
Lung Auscultation
•
Normal
– Tracheal sound
– Lung sound
•
•
•
Normal intensity (amplitude)
Reduced intensity : Impaired transmission
Increased intensity: Bronchial breathing
»
•
Improved transmission of expiratory component
Abnormal
– Musical sounds
•
•
•
Stridor
Wheeze: high pitched
Rhonchus: aka low pitched wheeze, snoring quality on auscultation
– Non musical
•
•
Pleural friction rub
Crackles
–
–
fine and
coarse
– Mixed
•
Squawk
– N Engl J Med 2014;370:744-51.DOI: 10.1056/NEJMra1302901
•
Fine crackles:
– not pathognomonic of idiopathic pulmonary fibrosis
•
also found in other interstitial diseases
–
asbestosis, nonspecific interstitial pneumonitis, interstitial fibrosis associated with connective-tissue disorders,
etc
– Properties
•
•
•
•
•
•
Not related to secretions
uninfluenced by cough
altered by gravity, changing or disappearing with changes in body position (e.g., bending forward).
usually heard during mid-to-late inspiration,
well perceived in dependent lung regions, not transmitted to the mouth.
Coarse crackles
•
•
•
•
•
•
•
may be related to secretions
tend to appear early during inspiration and throughout expiration
have a “popping” quality.
may be heard over any lung region,
usually transmitted to the mouth
can change or disappear with coughing,
but are not influenced by changes in body position
49. What is the approximate annual risk of rupture associated with a 6-cm abdominal aortic
aneurysm?
A. 1%
B.
10%
C.
20%
D.
50%
E.
75%
The best-laid schemes o' mice an' men
Gang aft agley,
•
Mea culpa
– I think I highlighted the wrong answer in correspondence
•
From lecture…
– Risk of rupture of an aneurysm related to diameter
– Rupture is uncommon < 5cm
• > 6cm annual risk of rupture = 9%
• > 8cm annual risk of rupture = 25%
– (5 year survival of patients with aneurysm > 5cm & not operated upon is 20%)
– Exponential
• 1% or less < 5.5 cm,
• 9.4% for one measuring 5.5 to 5.9 cm,
• 10.2% for one measuring 6.0 to 6.9 cm, and
• 32.5% for one measuring 7 cm or larger.
– N Engl J Med 2014; 371:2101-2108
35 wrong
46. Which one of the following statements about the treatment of iron deficiency anemia
is true?
A.
Helicobacter pylori infection may lead to iron deficiency that is refractory to oral
iron supplementation.
B.
Oral iron produces false positive results on faecal occult blood testing.
C.
Treating iron deficiency before the development of anaemia has proven benefits.
D.
Vitamin C can decrease the absorption of iron from oral supplements.
E.
Most of the iron needed daily (about 25 mg) is derived from intestinal absorption of
dietary iron.
Iron deficiency a good discussion in cases …
even if this question “too hard”
•
•
Half of the world’s population is infected with H. pylori
H. pylori infection decreases iron
–
–
–
•
competes with its human host for available iron,
reduces the bioavailability of vitamin C, and
leads to microerosions that cause bleeding.
Oral iron may cause dark stools but does not produce false positive results on tests for occult blood
–
–
Guaiac based fecal occult blood test — This test identifies hemoglobin by the presence of a peroxidase
reaction that turns guaiac-impregnated paper blue
immunologic assays for intact human hemoglobin, react only to human hemoglobin and do not usually
detect upper GI bleeding, since hemoglobin is digested in the small bowel.
•
The benefit of treating iron deficiency before the development of anemia remains uncertain.
•
D. The addition of vitamin C may IMPROVE the absorption of iron from oral supplements.
•
E. (A tough one) Since excess levels of iron can be toxic, its absorption is limited to 1 to 2 mg daily,
–
most of the iron needed daily (about 25 mg per) is derived from iron recycled by macrophages
•
phagocytose senescent erythrocytes.
32 wrong
23.
A 50 year old cleaner presents with a firm, irregular 1.5cm lump in the left breast. Axillary
examination is normal. Mammography demonstrates micro calcification in the lesion.
Which of the following is most appropriate next step?
A. Fine needle aspirate for cytology
B. Percutaneous core biopsy
C. Incisional biopsy
D. Excisional biopsy
E. Lumpectomy and axillary node clearance
41 wrong
6.
A 67 year old woman presents to the Emergency Department after a fall in the
bathroom with a painful left shoulder. X-Ray reveals a subcapital fracture of the
humerus.
What is the most appropriate treatment?
A. Collar and cuff for pain relief followed by early mobilization.
B. Excision of the head of the humerus
C. Full length arm plaster for 8 weeks
D. Insertion of a nail into the shaft of the humerus
E. Open reduction and stabilization of the fracture by plate and pins
31 wrong
A 17 year old student presents to her general practitioner with a 6 month history of
passing 5-7 loose motions per day. She describes intermittent right lower
abdominal pain, night sweats, lack of energy, weight loss of 5kg and intermittent
pain and swelling in her knees and ankles. Blood tests performed at her initial
visit demonstrate:
Test
Result
Normal Range
Hb
85 g/L
130-180
MCV
88
80-94
WCC
8.3 x 109/L
4.0-11.0
CRP
54.5 mg/L
<8.7
Albumin
31g/L
35-50
What histological finding is most likely on her ileal biopsies at colonoscopy?
A. Giardia lamblia trophozoites attached to the mucosa
B. Large, foamy PAS - positive macrophages
C. A monomorphic lymphoctyic infiltrate
D. Total villous atrophy
E. Non-caseating granulomata
Most likely IBD
and specifically Crohn’s disease
Giardia lamblia trophozoites attached to the mucosa
Giardiasis
Large, foamy PAS - positive macrophages
- Whipple’s disease
- Tropheryma whipplei
A monomorphic lymphoctyic infiltrate
suggestive of gastrointestinal lymphoma
Total villous atrophy
- duodenal biopsy in coeliac disease
Non-caseating granulomata
- Granuloma present in 35% Crohns disease
- Not in UC
29 wrong
All of the following can represent manifestations of end organ damage in symptomatic myeloma
EXCEPT FOR:
A. Hypercalcaemia
B. Renal Insufficiency
C. Sclerotic Bone Lesions
D. Anaemia
E. Recurrent Infections
Symptomatic Myeloma=CRAB features
•
•
•
•
HyperCalcaemia
Renal impairment
Anaemia
Bone disease- LYTIC, not Sclerotic
• Recurrent infection also common
35 wrong
20.
A 52 year old woman presents with a 4 month history of difficulty walking up stairs,
hanging clothes on the line and brushing her hair. She is a heavy smoker, has lost weight
and has had recurrent coughing, with occasional haemoptysis.
Which one of the following is the most likely diagnosis?
A. Polymyositis
B. Chronic Fatigue Syndrome
C. Severe Motor Neuropathy
D. Myasthenia Gravis
E. Motor Neuron Disease
Dermatomyositis and polymyositis
•
Dermatomyositis (DM) and polymyositis (PM)
–
–
idiopathic inflammatory myopathies
shared features of proximal skeletal muscle weakness and evidence of muscle inflammation
•
A non-classical presentation probably the most common
•
Classical presentation highly suggestive
–
–
–
•
Patients with the extramuscular manifestations of the antisynthetase syndrome viz
•
•
•
•
•
•
Symmetric proximal muscle weakness and marked elevation of muscle enzyme
Evidence suggesting an alternative diagnosis is lacking.
PLUS
rash: hyperkeratotic, fissured skin on the palmar and lateral aspects of the fingers
polyarthritis,
Raynaud phenomenon
interstitial lung disease,
particularly if an antisynthetase antibody + (most often anti-Jo-1)
Or Patients with a cutaneous finding that is relatively specific for dermatomyosiitis, such as
–
–
Gottron’s papules
heliotrope eruption
hyperkeratotic, fissured skin on the palmar and lateral aspects of the fingers
29 wrong
Which one of the following factors increases the risk of Barrett's oesophagus?
A.
B.
C.
D.
E.
Female sex.
Gastric infection with Helicobacter pylori
Obesity
Use of nonsteroidal antiinflammatory drugs (NSAIDs).
A diet high in fruits and vegetables
28wrong
17.
A 24 year-old woman with rheumatoid arthritis presents to her general practitioner with
right lower quadrant abdominal pain of 6 hours duration with associated nausea and
vomiting. She is on methotrexate weekly and 1 mg of prednisolone daily. Her rheumatoid
arthritis affects the joints of her hands, knees, and neck. Physical examination reveals fever
of 39C, right lower quadrant abdominal tenderness and rebound. Joint examination reveals
active synovitis in her hands and decreased flexion and extension of her neck.
Her blood tests reveal:
Test
Result
Normal Range
WCC
16 x 109/L
4.0-11.0
ALT
63 mmol/L
55
Glucose
6.0 mmol/L
3.0-7.7
What is the issue of most importance related to her anaesthetic and her rheumatoid
arthritis?
A. An increased risk of anesthetic-induced malignant hyperthermia
B. Potential cervical spine instability with intubation
C. Higher risk of intraoperative hypotension with spinal anesthetic
D. High likelihood of inadequate anesthesia due to medication interaction
E. Increased infection risk due to her immunosuppressants
27 wrong
25. A 73 year old woman with generalized sun damage to her skin is referred to a dermatologist
due to a 3cm diameter skin lesion on her right cheek. She is very distressed. She is adamant
that 6 weeks ago there was no lesion in evidence and that this lesion has grown extremely
rapidly over that period.
On examination she has a 3cm diameter, dome shaped, pink, fleshy tumour. It has a central
keratin core. There is no reaction in the surrounding tissues. It is not fixed to any other
structures and there is no lymphadenopathy.
What is the most likely diagnosis?
A. Basal cell carcinoma.
B. Keratoacanthoma.
C. Malignant melanoma.
D. Seborrhoeic keratosis.
E. Squamous cell carcinoma
26 wrong
35.
An 82 year old man presents with recurrent episodes of dizziness and one episode of
syncope associated with slow pulse, and spontaneous recovery. His current ECG shows
atrial fibrillation with ventricular response rate of 80/min.
Which one of the following is the MOST likely cause of his dizziness and syncope?
A. Ischaemic heart disease
C. Carotid sinus hypersensitivity
D. Sick sinus syndrome
E. Thyrotoxicosis
Sick sinus syndrome
• Characteristics include
– Frequent periods of inappropriate, and often severe bradycardia
– Sinus pauses, arrest, and sinoatrial (SA) exit block with, and often
without, appropriate atrial and junctional escape rhythms. The failure
of escape pacemakers may lead to symptoms including syncope
– Alternating bradycardia and atrial tachyarrhythmias in over 50%
• i.e.Tachycardia-bradycardia syndrome
• AF most common
• Atrial flutter and paroxysmal SVT may also occur.
– Atrial arrhythmias seem to develop slowly over time possibly the
result of a progressive pathological process that affects the SA node
and the atrium.
– (subnormal heart rate response to exercise) chronotropic
incompetence as either a near constant nontachycardic (monotonic)
heart rate over a 24-hour period
Pathological sinus bradycardia
-
Sick sinus syndrome
Drugs
-
Exaggerated vagal activity
- Carotid sinus hypersensitivity
- Vomiting or coughing
- Valsalva manoeuvre when straining at stool
- Prolonged standing via a Bezold-Jarisch reflex
Increased intracranial pressure
Acute myocardial infarction
Athletes
Obstructive sleep apnoea
-
Ischaemic heart disease
- Sinus bradycardia after inferior AMI
- (RCA supplies SA in 60%),
- usually transient caused by increased vagal tone
- Less commonly ischemia of the SA node and as a reperfusion arrhythmia following
fibrinolysis;
- Of course medications: beta-blockade, calcium channel blocker, or digoxin
Other causes
Transient ischaemic attack (TIA)
- Posterior circulation TIA previously been considered a common cause
for syncope.
- Rarely causes true syncopal symptoms.
Thyrotoxicosis
- Expect to cause tachycardia/ tachyarrhythmia
- Sinus tachycardia, atrial fibrillation
29 wrong
A 26 year old woman presents with a history of colour change in her fingers in the cold for several
years. These changes have been more severe this winter and she has had chillblains as a
result. She has no other features of scleroderma.
Which one of the following alternatives is the most appropriate management?
A. Perform an antinuclear antibody test.
B. Commence D-penicillamine
C. Commence a calcium channel blocker
D. Commence aspirin
E. Advise her to wear gloves and avoid changes in temperature if possible
Pernio
(aka chilblains or perniosis)
•
•
•
•
Cold-induced erythrocyanotic skin lesions.
"chilblains” derived from the Old English words "chill" and "blegen" (sore)
Young and middle-aged women are most commonly affected by pernio
The pathophysiology of pernio is not known.
•
Differential diagnosis
– Acrocyanosis
• chronic coolness and violaceous discoloration of the hands and feet, rather than the papular eruption
• usually asymptomatic
–
Raynaud phenomenon
• pallor on the digits followed by blue and then red
• lasting for 15 to 20 minutes.
• papules, plaques, and nodular lesions of pernio are absent.
• Notable for relationship to autoimmune disease
–
Cold panniculitis
• popsicle panniculitis is a form of lobular panniculitis that results from direct cold exposure.
• Very common in young children
–
Cryoglobulinemia and cryofibrinogenemia
• Hyperviscosity with monoclonal CG that form cold precipitates
– Underlying lymphoproliferative disorder
– There is another group of disorders associated with cryoglobulins that don’t cause cold related disorders
Management
• Patients should be instructed to keep the affected areas
warm by wearing appropriately insulated clothing and
avoiding unprotected exposure to cold conditions.
• For adults with refractory pernio, options:
– Supprted by modest data
• Nifedipine
– Anecdotal evidence
•
•
•
•
•
intralesional corticosteroid injection
oral prednisone
prazosin,
weight gain
Pentoxifylline, etc
24 wrong
14.
All of the following are true EXCEPT:
A. Rinne’s and Weber’s tests are especially useful if there is asymmetric hearing loss
B. In Weber’s test, if there is conductive hearing loss the sound is heard in the
hearing ear
worse
C. In Weber’s test, if there is a sensorineural loss the sound is heard in the better ear
D. Bone conduction is normally better than air conduction
E. In conductive hearing loss, bone conduction is better than air conduction
23 wrong
A 32 year old plumber presents to the Emergency Department with a two day history of fever,
headache and photophobia. There is no rash.
A lumbar puncture is performed and CSF analysis reveals 220 white blood cells with 20
polymorphs and 200 mononuclear cells, elevated protein 0.8 g/L (2.8-4.0) and glucose 4.0
mmol/L (2.8-4.0).
Which one of the following organisms is the MOST likely pathogen?
A. Cryptococcus neoformans
B. Mycobacterium tuberculosis
C. Streptococcus pneumoniae
D. Neisseria meningitidis
E. Enterovirus
24 wrong
51. Mr Catania is 72 years old and presents with increasing shortness of breath on exertion. He
has a past medical history of angina, hypertension and systolic heart failure. Clinical
examination reveals tachycardia of 102 beats per min and a gallop rhythmn on ausculation of
the heart. He is currently on frusemide and digoxin and his creatinine and potassium are
within normal limits.
You suspect that his heart failure is worsening, which of the following medications should
be added add first to optimise his treatment?
A. Spironolactone
B.
Perindopril
C.
Candesartan
D.
Carvedilol
E.
Amiodarone
22 wrong
Mrs Irregular is 68 years old and presents to a GP practice with increasing symptoms of chronic
heart failure (NYHA Class II). She is currently on appropriate doses of perindopril,
frusemide and carvedilol. A recent echocardiogram showed significant left ventricular
systolic dysfunction, her 12 lead ECG has a regular rhythm and she has normal potassium
and serum creatinine.
It is suspected that there is progression of her chronic disease. What drug class should be
introduced at this stage?
A. Digoxin
B.
An aldosterone antagonist
C.
Enoxaparin
D.
A nitrate
E.
A thiazide diuretic
•
•
•
National Prescribing Curriculum: Chronic heart failure module Q1
Typical presentation of worsening heart failure in the setting of “old fashioned” treatment of heart failure.
Standard treatment for chronic heart failure include
– Regardless of cause
• ACE inhibitor
• loop diuretic (symptomatic but no prognostic benefit)
• Beta blocker when improved
• Spironolactone is recommended for patients who remain symptomatic, despite appropriate
doses of ACEIs and beta blocker
–
–
Spironolactone
» (RALES study; NEJM 1999: 341:709-717
Eplerenone
» (EMPHASIS-HF study; NEJM 2011; 364:11-21
• Vaccination against influenza (annual) and pneumococcal infection.
–
Management of the underlying disease
• Non-pharmacological and
• Other drug measures e.g. aspirin, and statin
Certificate of Completion
This is to certify that
Tim Pianta
has completed
Chronic heart failure 2015
24 May 2015
A module from the National Prescribing Curriculum.
UrRlREKM8J
24.
A 35 year old female presents with progressive dysphagia and recent vomiting of old food, associated with weight loss
of 6kg. Her barium swallow is shown below
What is the most likely diagnosis?
A. Achalasia
B. Gastro-oesophageal Reflux Disease
C. Pharyngeal Pouch
D. Hiatus Hernia
E. Scleroderma
Barium swallow
24 wrong
47.
Which of the following statements about the motor manifestations of Parkinson’s Disease
is TRUE?
A. A wide-based gait, uncoordinated limb movements, and nystagmus are common
features.
B.
Festination may be described as the tendancy “to take much quicker and shorter
steps, and thereby to adopt unwillingly a running pace".
C.
Tremors are typically action tremors, in which the tremor occurs when the affected
limb is being used.
D.
Dystonia is always a reversible levodopa-induced motor complication that can be
treated by adjusting levodopa dosing.
E.
Among the primary motor features of Parkinson’s disease, postural instability is the
most responsive to dopaminergic therapies.
Parkinsons disease
A.
-
A wide-based gait, uncoordinated limb movements, and nystagmus
Cerebellar features, cf extrapyramidal
B. Original description by Parkinson J. An Essay on the Shaking Palsy, Sherwood, Neely, and Jones, London
1817. Remains elegant.
C. The tremor in PD,
typically described as "pill-rolling,”
is a rest tremor, meaning that it is most noticeable when the tremulous body part is supported by gravity
and not engaged in purposeful activities.
Usu between 3 and 7 Hz, and most often is between 4 and 5 Hz.
the presenting symptom in approximately 70 percent of patients with PD.
D. Dyskinesia described, cf dystonia vs dyskinesia slides from lecture (a tough one, but wrong)
E. Cardinal manifestations:
Tremor
Rigidity.
Akinesia(/bradykinesia)
Postural symptoms.: From lecture the least responsive to threapies
21 wrong
48. A 38 year old man commenced antiretroviral therapy (ART) 7 weeks ago for newly
diagnosed HIV. At that stage his CD4 count was with 80 x 109 cells/L. He now presents
with a fever of 38.0 C and a 3cm firm lump in his neck, behind his mandible. Which of
the following is true?
A. This complication likely represents poor adherence to his new medications.
B.
He should undergo a lymph node biopsy with the entire sample sent in formalin for
histopathology.
C.
He likely has drug-resistant HIV and his ART should be changed
D.
Blood cultures will likely be positive and can direct antimicrobial therapy.
E.
This complication is “paradoxically” due to an increase in the numbers of CD45RO+
memory T cells.
immune reconstitution syndrome
Here likely indolent Mycobacterium avium complex (MAC, M. avium and M.
intracellulare) as discussed in lecture.
Therefore:
A and C. This response likely represents the beneficial effect of ART not resistance to
medication
B. He should undergo a lymph node biopsy some sample sent for histology, but also
fresh for culture including mycobacterial culture. (trap discussed in lecture notes)
D. Although appropriate investigations, blood cultures will likely be negative.
Treatment will most likely be guided by lymph node biopsy. (need for biopsy discussed
in lecture)
E.
This complication is “paradoxically” due to an increase in the numbers of
CD45RO+ memory T cells
12.
A 30 year old man presents with severe 'dandruff' and pruritus of the scalp. Scaling also
affects his eyelids.
Which one of the following is the most likely cause?
A. Allergic reaction to his shampoo
B. Psoriasis
C. Atopic eczema
D. Seborrhoeic dermatitis
E. Contact dermatitis.
Scalp Psoriasis
•
•
•
Leads to scalp itch and irritation
Silvery scale ++
Responds to topical therapy with LPC, Salicylic acid, topical
corticosteroids, calcipotriol.
Psoriasis: Periauricular, auricular involvement
11.
A 68 year old woman presents to the Emergency Department with chest pain followed by
sudden collapse with loss of consciousness. She has a rapid weak pulse. Her ECG shows a
regular wide complex tachycardia.
Which one of the following is the most likely diagnosis?
A. Atrial Fibrillation
B. Ventricular Fibrillation
C. Atrial Flutter
D. Supraventricular Tachycardia
E. Ventricular Tachycardia
Ventricular Tachycardia
• Wide complex tachycardia (WCT)
– QRS ≥120 msec
– challenging for two reasons:
• Diagnosing the arrhythmia is difficult
– most WCTs are due to VT,
– the differential diagnosis includes a variety of SVTs.
– Diagnostic algorithms to differentiate these two etiologies
are complex and imperfect.
• Urgent therapy is often required
– Patients may be unstable at the onset of the arrhythmia or
deteriorate rapidly at any time, particularly if the WCT is
VT
22.
A 75 year old previously well woman is brought to the Emergency Department following a
fall onto her outstretched right hand when walking in the street. She is in pain and has a
tender deformity just above her right wrist. X-Ray of the right forearm reveals an
undisplaced fracture of the distal radius (a Colle’s fracture). She is given analgesia and a
forearm plaster is applied. She returns to the Emergency Department the following day
complaining of increased pain in her forearm.
On examination the fingers of her right hand are cyanosed, cold and there is reduced
sensation to light touch.
What is the most appropriate management?
A. Divide her plaster cast
B. Increase her oral analgesia
C. Intramuscular analgesia
D. X-ray of her cervical spine to exclude a compression fracture
E. X-ray of her right forearm, looking for displacement of the fracture
32.
A 69 year-old man is admitted for a radical prostatectomy. On day 2 post-operatively, he
develops severe left-sided flank pain that extends from his back around to his umbilicus.
His vital signs are BP 149/94, pulse 92/minute, T 37.4C, respiratory rate 12/minute. He has
multiple, clustered vesicular lesions on an erythematous base that correspond with the
area of pain.
What is the most appropriate therapy at this time?
A. Acyclovir
B. Azathioprine
C. Ceftriaxone
D. Fluvoxacillin
E. Morphine
38.
A 32 year old man presents with a history of chronic productive cough, occasionally
associated with fever, and copious, purulent sputum often streaked with blood. On
examination he is clubbed. Chest Xray reveals streaky infiltrates in both lung fields.
Which one of the following is the most likely diagnosis?
A. Bronchiectasis
B. Empyema
C. Tuberculosis
D. Lung abscess
E. Recurrent staphylococcal pneumonia
45.
A 68 year old man presents with a 4 week history of severe headache. He has also felt
vaguely unwell, lost 5kg in weight and has ache in the neck and shoulders. He remarks that
wearing a hat is uncomfortable and he has some tenderness when he brushes his hair.
Which one of the following is the MOST likely diagnosis?
A. Chronic meningitis
B. Intracranial tumour
C. Migraine
D. Temporal Arteritis
E. Cluster headache
54. Which one of the following statements comparing oesophageal adenocarcinoma with
oesophageal squamous-cell carcinoma is true?
A. Alcohol consumption is a risk factor for both subtypes of oesophageal cancer.
B.
Oesophageal adenocarcinoma is equally common among men and women, whereas
the squamous-cell subtype is more common in men.
C.
Most adenocarcinoma lesions are found in the distal oesophagus, whereas the
squamous-cell subtype is more common in the proximal to middle oesophagus.
D.
Worldwide, the adenocarcinoma subtype is more prevalent than the squamous-cell
subtype.
E.
Barret’s oesophagus is a precursor to squamous-cell carcinoma.
Summary: N Engl J Med 2014; 371:2499-2509 December 25, 2014
28. A 52 year old woman presents with 24 hours of gradual onset of right frontal headache
(“behind the right eye”) with associated diplopia.
On examination she has a right ptosis, her right pupil is larger than the left and sluggishly
reactive to light, and her right eye is deviated inferiorly and laterally. She has no other
neurological deficit. CT scan of the brain is normal.
Which one of the following is the MOST likely diagnosis?
A. Viral meningitis
B. Intracranial aneurysm
C. Migraine
D. Temporal arteritis
E. Subarachnoid haemorrhage
Third nerve palsy
•
Pupil-involved third nerve palsy should be assumed to be due to aneurysmal compression
until proven otherwise.
– Most classically posterior communicating artery
• Also reported: internal carotid artery and basilar artery
– Ix: MRI and MRA (or CTA);
• If negative, strongly consider catheter angiogram
•
Ischemic “diabetic” third nerve lesions typically present with intact pupillary function (80 to
90%),
– probably lack of damage to the superficial periphery
• where the majority of pupillomotor fibers are thought to pass
• When the pupil is involved, impairment is usually incomplete
– Atheroscleotic
– Giant cell arteritis
•
Less common causes
– Trauma
– Migraine
33.
A 73 year old woman is referred to a dermatologist for further treatment of a lesion on
her right cheek. On examination she has a 1 cm diameter, raised, ulcerated lesion on her
right cheek which has ‘pearly’ edges. There is no reaction in the surrounding tissues. It is
mobile and there is no lymphadenopathy.
What is the most appropriate management?
A. Review in 3 months
B. Apply topical 5 fluoruracil (5FU)
C. Apply topical steroid cream
D. Apply liquid nitrogen
E. Excisional biopsy
8.
A 75 year old gentleman presents with shortness of breath. Investigations including a CXR
reveal a unilateral pleural effusion. Which of the following statements regarding pleural
effusions is CORRECT?
A. A transudate is suggested if pleural fluid protein is high (>3g/dL)
B. Congestive cardiac failure is a common cause of a exudate pleural effusion
C. Malignant pleural effusions are usually transudate in nature
D. A large unilateral pleural effusion in the elderly is highly suspicious for
malignancy
E. Medical conditions associated with hypoalbuminaemia (renal failure, cirrhosis) are
often associated with exudate pleural effusions
31. A 38 year old male with a past history of three ileal resections for Crohn’s disease consults his
general practitioner because of increasing fatigue. There has been no change from his
normal bowel habit.
Physical examination is normal apart from a surgical scar on the abdominal wall. A full blood
count reveals
Test
Result
Normal Range
Hb
112 g/L
130-180
MCV
102
80-94
WCC
3.9 x 109/L
4.0-11.0
Plt
145 x 109/L
150-450
CRP
5 mg/L
<8.7
Which of the following is the most appropriate treatment for his anaemia?
A. Oral prednisolone
B. Oral folic acid
C. Oral iron
D. Blood transfusion
E. Parenteral vitamin B12
34.
All of the following statements regarding brain tumours are true EXCEPT:
A. A temporal lobe mass often presents with mood disturbance or personality change
B. Headache associated with raised ICP is often worse in the morning
C. Steroids are important in the initial management of most brain tumours
D. Metastatic brain tumours are often from lung and breast primaries
E. Neuroepithelial tumours (gliomas) are the most common type of brian tumour
5.
A 65 year old man presents to emergency following an episode of loss of consciousness.
His ECG is below:
What is the most likely cause of his loss of consciousness?
A. Long QT syndrome
B. Rapid atrial fibrillation
C. Acute Myocardial Infarction
D. Neurocardiogenic syncope
E. Pulmonary Embolism
•
QTc = QT interval ÷ square root of the RR interval (in sec)
–
•
The QT interval varies inversely with the heart rate
QTc over the 99th percentile should be considered abnormally prolonged
– VIZ QTc of
• >470 ms for men and
• >480 ms for women.
• >500 ms highly abnormal for both men and women.
40.
A 65 year old woman is brought to the Emergency Department by her husband because of
a 24 hour history of colicky central abdominal pain. She has been unable to keep food or
liquid down and has vomited bile stained fluid several times over the last 6 hours. She has
not used her bowels over this time.
On examination she is in obvious pain. Her vital signs are PR 110/minute, BP 130/80, RR
20/minute, T 36.7C. She has dry mucous membranes and her jugular venous pressure is
only visible when she lies flat. Abdominal examination reveals mild generalized distension
but there is no tenderness or organomegaly. She has active high pitched bowel sounds.
The most appropriate initial investigation is:
A. Gastrograffin enema
B. Abdominal CT scan
C. Upper g.i. endoscopy
D. Serum amylase
E. Erect and supine abdominal X Ray
43.
Mr HT is a 50 year old gentleman with a past medical history of hepatitis C and
osteoarthritis presents with a several week history of increasing lethargy, abdominal
distension and swelling of his ankles. He denies any fevers, chills or rigors, and has no
abdominal pain or shortness of breath.
On examination, he is alert and orientated, and not clinically jaundiced. His abdomen is
distended, but soft and non-tender, and bowel sounds are present. He has pitting oedema
to his knees bilaterally, JVP is 3cm and chest is clear.
What is the most likely cause of his abdominal distension?
A. Portal hypertension
B. Right heart failure
C. Nephrotic Syndrome
D. Spontaneous Bacterial Peritonitis
E. Bowel Obstruction
52. Mr Jones is 72 years old and presents with acute shortness of breath. On questioning he
has recently had an exacerbation of his rheumatoid arthritis and his GP has increased
prednisolone from 5 mg to 25 mg a day. An acute exacerbation of his chronic heart failure
due to fluid retention secondary to the corticosteroid is suspected. What intervention
would be most beneficial?
You suspect that his heart failure is worsening, which of the following medications should
be added add first to optimise his treatment?
A. Stop the prednisolone
B.
Commence thiazide diuretic
C.
Increase or add a loop diuretic
D.
Use of paracetamol
E.
Add digoxin
29. A 34 year-old dairy farmer presents with increasing shortness of breath for 6 months so
that she can no longer jog or climb stairs easily. She has also noticed her fingers turning blue
and white in the cold, and they feel increasingly tight. She does not smoke. Her only
medication is the oral contraceptive pill.
Examination shows a thin woman with respiratory rate of 24/minute and oxygen saturation
of 89% on room air. She has bilateral diffuse fine crackles in her lungs.
What is the most likely underlying mechanism of her lung problem?
A. Pulmonary artery hypertension
B. Alveolar destruction
C. Bronchiolar spasm
D. Interstitial fibrosis
E. Alveolar haemorrhage
27. A 72 year-old man presents to the Emergency Department unable to urinate for the past 24
hours. He reports lower abdominal pain and recent difficulties starting his urinary stream.
Which one of the following abdominal findings is most likely to confirm your clinical
diagnosis?
A. Generalized tympany
B. Renal mass
C. Suprapubic dullness
D. Shifting dullness
E. Flank bruit
42.
Which one of the following is NOT associated with the development of squamous cell
carcinoma of the skin?
A. The application of topical arsenic containing preparations
B. Prolonged sun exposure
C. Pre-existing hypothyroidism
D. Immunosuppressive therapy
E. Scarring in burns
19.
A 43 year old van driver is reviewed in Surgical Outpatients 2 months after a prolonged
hospital admission following a high speed motor vehicle accident in which he sustained
multiple fractures and extensive soft tissue injuries. He has made a good recovery but
describes difficulty using his right hand.
On examination there is mild wasting of the thenar eminence and weakness of abduction
of the thumb. All reflexes are intact. He has diminished pin-prick sensation over the
palmar surface of the hand, thumb, index finger, middle finger and the lateral half of the
ring finger.
What is the most likely diagnosis?
A. Brachial plexus lesion
B. C6 and C7 root lesion
C. Median nerve lesion
D. Radial nerve lesion
E. Ulnar nerve lesion
36.
A 42 year old man presents to emergency after falling while learning to snowboard. He fell
with his hand outstretched behind him. The hand is not deformed. He is tender over the
thenar eminence and the ‘snuff box’. Thumb and 5th finger opposition is weak due to
pain. Neurovascular examination is normal.
The most likely diagnosis is:
A. Carpo-metacarpophalangeal dislocation
B. Ulnar fracture
C. Scaphoid fracture
D. Colles’ fracture (radial head)
E. Bennett’s fracture (base of first metacarpal)
4.
All of the following statements regarding lung cancer are correct EXCEPT FOR:
A. Small Cell Carcinomas are strongly associated with smoking
B. Small Cell Carcinomas are typically exquisitely chemo-sensitive and surgery is not
usually the recommended treatment
C. Adenocarcinoma is the most common type of non small cell lung cancer
D. Lung Cancer typically metastasizes to the adrenals, liver, brain and bone
E. Small Cell Carcinomas tend to be slow growing and are associated with better overall
prognosis
10.
A 73 year-old man presents to his general practitioner with 2 months of fatigue with a 3 kg
weight loss. Conjunctivae and nails are pale. Cardiovascular examination shows a 2/6 ejection
murmur. Abdominal examination is normal. One 0.5 cm cervical node is mobile and nontender, and shotty inguinal lymph nodes are present bilaterally. Prostate is enlarged to twice
normal and is smooth and non-tender. Initial blood tests reveal:
Test
Result
Normal Range
Hb
92g/L
135-170
WCC
8.5 x 109/L
4.0-11.0
Plt
300 x 109/L
150-450
MCV
75
80-95
Iron
4 μmol/L
9-30
Ferritin
6 μg/L
9-136
ESR
49mm
<12
What is the most appropriate investigation at this time?
A. Abdominal ultrasound
B. Bone marrow biopsy
C. CT scan of the chest
D. Colonoscopy
E. Upper GI Endoscopy
26. With respect to diabetic nephropathy, all of the following are true EXCEPT:
A. Hypertension accelerates the progression of diabetic nephropathy
B. Diabetic nephropathy is a leading cause of end stage renal failure in Australia
C. Nephropathy is one of the macrovascular complications of diabetes
D. Diabetic nephropathy may not be detected on standard dipstick
E. The most common screening test for diabetic nephropathy is albumin:creatinine ratio
41.
Which one of the statements regarding fibroadenoma of the breast is LEAST correct?
A. Well defined mammographic density
B. Palpable breast lump
C. High risk of subsequent breast carcinoma
D. May have atypical fine needle aspiration cytology
E. Predominantly in younger age group
7.
A 64-year-old businessman presents to the Emergency Department with 8 hours of
palpitations, chest pressure, and mild shortness of breath. His only past medical history is
hypertension, treated with hydrochlorothiazide.
On examination he looks uncomfortable. His HR is 140/minute, blood pressure 142/88
mmHg, respiration 20/minute, temperature 37.1°C. Eyes show bilateral lid lag. His thyroid
gland is nodular and twice normal size. Cardiovascular examination reveals a JVP of 3 cm
above the sternal edge, apex beat not displaced, dual heart sounds with a 2/6 ejection
murmur at the left lower sternal border. Ankle reflexes are 2+ and symmetrical.
The most likely additional physical finding in this patient would be:
A. Pericardial Rub
B. Carotid Bruits
C. Fine symmetrical tremor
D. Delayed Achilles reflexes
E. Pulsus Paradoxus
21.
All of the following statements regarding hypothyroidism are true EXCEPT:
A. Malaise, fatigue, cold intolerance and constipation are common associated
symptoms
B. Examination findings may include delayed tendon reflexes and bradycardia
C. Hypothyroidism is usually associated with low TSH and elevated free T4
D. Hypothyroidism is usually treated with thyroid hormone replacement therapy
E. A thyroid uptake nuclear scan is generally not required in investigation of
hypothyroidism
37.
A 27 year old primary school teacher presents to her general practitioner with a 6 month
history of passing 2-3 loose pale motions per day, with associated abdominal discomfort
and bloating, weight loss of 8kg, lethargy and recurrent mouth ulcers.
On examination she is pale with no other abnormality. Initial blood tests reveal positive
antibodies to transglutaminase (tTG-IgA) and gliadin (DPG-IgA and IgG). She is referred for
a small bowel biopsy.
What histological finding is most likely on her small bowel biopsy?
A. Giardia lamblia in the intervillous spaces
B. Large, foamy PAS - positive macrophages
C. Submucosal neutrophil infiltrate
D. Total villous atrophy
E. Transmural inflammation with non-caseating granulomata
39.
A 39 year old previously well advertising executive is brought to the Emergency
Department by his wife 30 minutes after the abrupt onset of severe headache while he
was watching television. He vomited and became drowsy. He smokes 10 cigarettes/day
and drinks 2-3 glasses of beer or wine most days. There is no history of trauma.
On examination he is confused and drowsy. He has neck stiffness and bilateral
papilloedema. An urgent CT scan brain shows blood in the interhemispheric fissure, the
Sylvian fissures and the third ventricle.
What is the most likely underlying cause of his haemorrhage?
A. Systemic coagulopathy
B. Rupture of a berry aneurysm
C. Tuberculous meningitis
D. Leptomeningeal tumour
E. Longstanding hypertension
Revision Exam SAQ 2015
Question 1
Mr JT is a 58 year old banker who was diagnosed with Type 2 diabetes mellitus 6 years ago. He also has a
history of osteoarthritis and hypertension. His current medications are metformin 1000mg bd and perindopril
5mg daily. He hasn’t seen a doctor for a while, but has recently moved to Melbourne and wants to improve his
diabetic control. He comes to see you for ongoing management of his diabetes.
A. List four examination findings which would be important to look for when examining Mr JT with respect to his diabetes.
(To receive full marks you must also detail why these examination findings are important) (4 marks)
•
•
•
•
•
•
Weight and height to calculate BMI
Fundoscopy – diabetic retinopathy
Postural BP – autonomic neuropathy
Cardiovascular examination – ischaemic cardiomyopathy (displaced apex)
Peripheral pulses, Bruits – PVD
Peripheral sensation/Reflexes – peripheral neuropathy
B. What investigations would you request at this stage and why? (4 marks)
•
•
•
•
HbA1c (long term BSL control)
UEC (renal function)
Urine A:Cr ratio (?diabetic nephropathy)
Fasting cholesterol/triglycerides (CVD risk factors)
Following the results of your history, examination and investigations, you decide Mr JT’s current diabetic
control is sub-optimal.
C. List three factors that are important to take into consideration when considering what adjustments should be made to Mr JT’s
medication regime to improve his diabetic control (3 marks)
•
•
•
•
•
•
•
BSL control and HbA1c (above target suggesting control is poor and therapy needs to be escalated)
Occupation (risk of hypoglycaemia)
Potential for side effects from medication (renal impairment, history of CCF)
Weight
Duration of diabetes
Compliance/education
Exercise
You decide that it would be appropriate to commence Mr JT on a sulphonylurea medication (Gliclazide 30mg
daily) to attempt to improve his BSL control.
D. Using the Medication List below the table, Match the medication to its mechanism of action (5 marks)
Mechanism of Action
Medication
Improve insulin release, Delay gastric GLP-1 analogues eg Exenatide
emptying
Increase insulin secretion
DDPIV inhibitors (eg Sitagliptin)
Inhibits hepatic glucose production
Metformin
Stimulate beta cell insulin release
Sulphonylureas (eg Gliclazide)
Inhibits GIT CHO absorption
Acarbose
MEDICATION LIST
Mr JT commences Gliclazide 30mg daily, and continues on Metformin. Pleasingly his BSL control improves. He
comes back to see you 6 months later and tells you as he has been put on the wait list for an elective total knee
replacement.
E. List what steps you would take with regards to managing Mr JT’s diabetes peri-operatively (with respect to BSL and medication
management). (4 marks)
•
•
•
•
cease meds 12 hours pre
monitor BSL 4/24ly on day of operation
Treat <4 (iv dextrose) or >10 (supplemental insulin)
Resume orals when back on normal diet
Question 2
Mr LM is a 45 year old gentleman with no significant past medical history who has been generally unwell for
the last several months. He has noted loose stools, up to 10 times per day, and has noted some blood and
mucous mixed in with his bowel motions. He also notes some crampy abdominal pain, as well as urgency and
tenesmus.
A. What other information would be important to determine on history taking to establish a cause for Mr LM’s symptoms? (4
marks – 1 mark per question)
•
•
•
•
•
Constitutional symptoms, LOW
Recent travel
Recent antibiotics
Unwell contacts
Family history IBD
B. List your differential diagnosis for Mr LM’s presentation (2 marks)
•
•
•
Infection (Salmonella, Shigella, Yersinia, Entamoeba histolytica)
Inflammatory Bowel Disease
CRC
Clinical approach to diarrhoea
Fulfils Rome III Criteria
Other causes excluded
No red-flags*
Stool appearance
= IBS
Bloody diarrhoea
Exclude haemorrhoids
“Diarrhoea”
• Take a comprehensive history & build
up the clinical picture
• Clarify description of diarrhoea
• Exclude issues like faecal incontinence
or constipation with overflow which could
mimic diarrhoea
Watery diarrhoea
Steatorrhoea
• FBE, coeliac serology, nutritional screen,
inflammatory markers, thyroid function
• Faecal testing (microscopy/culture, wbc/rbc,
fat)
• Pathogen screen
• Colonoscopy + biopsy
* Weight loss, rectal
(PR) bleeding,
nocturnal
symptoms, age >45
Malabsorption work-up
• Coeliac serology
• Gastroscopy
Osmotic
Secretory
Response to fasting
High osmotic gap
Typically large volume
Unresponsive to fasting
Low osmotic gap
• Hydrogen/methane
breath testing
• Laxative screen
• CT scan
• Response to fasting
• Screen for hormonesecreting tumours
• Pancreatic assessment:
- CT scan
- Faecal elastase
- Endoscopic retorgrade
pancreatography (ERCP)
- Other
C. What investigations would you order to determine a cause for Mr LM’s presentation? You must list a reason for ordering each
investigation to receive full marks. (4 marks)
•
•
•
•
•
•
Faeces MCS: ?infectious aetiology, leukocytes more suggestive of IBD
Faeces CDT
FBE: anaemia (malabsorption Fe), WCC raised in infection
Inflammatory markers: ESR, CRP raised in inflammatory and infective conditions
B12, Folate, Fe studies, Vitamin D: to assess for malabsorption
Colonoscopy: histology for diagnosis IBD
Following the results of further investigations, you diagnose Mr LM with inflammatory bowel disease.
D. Complete the table below, highlighting the differences between Crohn’s Disease and Ulcerative Colitis with respect to typical
symptoms, anatomical distribution and histological findings (8 marks)
Symptoms
U.C
Frequent episodes Diarrhoea, blood , mucous
Urgency and tenesmus are
Crohns
Depends on region, common
ileocaecal
-Abdo Pain, wt loss, fever
Colonic
often a feature of distal disease -Diarrhoea, bleeding pain on
defaecation
Other symptoms include
abdominal cramps, weight loss
and fever in severe cases
Extraintestinal
manifestations
Perianal
-tags, fistulae, fissures, abscess
Extra-intestinal features include
arthritis, uveitis and rashes
Site
U.C
-Affects only the colon
Crohns
-Affects any part GIT
-Begins in rectum and extends
prox in varying degrees
-Continuous involvement
-Oral (apthous ulcers) and
Perianal disease
-Discontinuous involvement (Skip
lesions)
Pathology
Ulcerative Colitis
Macro-
Crohn’s Disease
Red mucosa, bleeds easy
-Ulcers and pseudopolyps in
severe disease
Deep ulcers and fissures in
mucosa-cobblestone appearance
Beefy red thickened bowel with fat
wrapping of small bowel
Micro-Mucosal inflammation
-No granulomata
-Goblet cell depletion
-Crypt abscesses
-Transmural inflammation
-Granulomas present in 50%
Crohn’s or U.C.
Crohn’s
List 4 treatment options for IBD
• Steroids (oral and topical)
• 5-ASA compounds (Sulphasalazine)
• ImmunosupressantsAzathioprine,
Methotrexate(CD)
• Biologicals (Crohns) (Monoclonal Ab)
• Surgery
Others• Metronidazole in severe perianal CD
• Enteral nutrition
E. List 4 treatment options for IBD (2points)
•
•
•
•
•
Steroids (oral and topical)
5-ASA compounds (Sulphasalazine)
Immunosupressants (Azathioprine, Methotrexate)
Biologicals (Crohns) (Monoclonal Ab)
Surgery
Medical Interview
Practice OSCE, MD2 5/6/15
71yo woman presents to local GP with
worsening cough and long standing shortness
of breath
You have 7 minutes to interview the patient and then 2 minutes
to answer clinical questions
Clarifies the nature of the
presenting problem-Cough
•
•
•
•
•
Nature cough-productive of phlegm (1)
Volume-Table spoon full/day (1)
Colour- discoloured grey (1)
Streaked with blood (bright red)(1)
Normally has a small amount of phlegm in
mornings (1)
Further History
• Aggravating factors(1)
• Relieving factors(1)
•
•
•
•
•
•
•
•
•
Asks about associated symptomsChange in Exercise tolerance (1)
Orthopnea/PND(1)
SOA(1)
Fever (1)
Chest pain (1)
Trauma- no bleeding elsewhere (eg nose) (1)
Weight loss (1)
Rash, arthralgias (1)
Other relevant history
•
•
•
•
•
•
•
•
•
Recent travel (1)
Smoking(1)
Immobility (1)
previous DVT/PE(1)
Exposure to TB (1)
Asks about routine medication (1)
Past Surgical and medical history (1)
Social history (1)
Vaccinations(1)
Describe TWO differential diagnoses for patient’s presentation and the history that supports
your DDx (4)
•
•
•
•
•
•
•
•
-Lung Carcinoma(1)-haemoptysis/cough/unintentional weight loss/worsening SOB
-Infective exacerbation COPD(1)-change in cough, productive, fever
-PE(1)-haemoptysis
-Pneumonia(1)-change in cough, productive, fever
-Cardiac failure (1/2)
-Bronchiectasis(1/2)
-TB (1/2)
-Abscess(1/2)
Please review the patients CXR, describe TWO abnormalities(2)
•
Large left midzone mass
•
Hyperinflated lungs c/w COPD
Describe TWO investigations that might help you establish the diagnosis of a
LUNG MASS, you must state how that test will help(2)
• Sputum cytology(1)
• Bronchoscopy(1)
– Standard
– Endobronchial ultrasound (EBUS)
• Biopsy-either CT guided OR Surgical Biopsy(1)
• PET scan(1)
General feedback
• Balance of open and closed questions
• Marks lost in Associated Features
-quick systems review for other causes missed
Eg cardiac
• Marks lost in other relevant history
Eg risk factors for DVT
CLINICAL REASONING
Consider the identification of relevant positive and negative finding and how the student used this
information to make a diagnosis (out of 4)
Active Listening Skills
•
•
•
•
•
•
•
criteria such as -maintains eye contact
open posture
receptive facial expressions
effective verbal and non-verbal techniques eg paraphrasing/clarification/restatement
didn't interrupt
good rapport
no technical terms
Instructions for students
EXAMINATION STATION 5th June 2015
50 year old male presents to ED with sudden
onset sharp persistent epigastric pain with
associated vomiting. Please examine this
patient in the emergency department.
You have 7 minutes to examine the patient then 2 minutes to
answer questions
• Introduce self, asking for consent
• Hand Wash-(1)
•
1.
2.
3.
InspectionPosition of patient: lying down, arms by side, 1pillow(1)
Adequate exposure of patient-nipples to groin(1)
Obvious inspection of patient and room(1)
Assessment
General inspection of hands (inc. Dupuytren’s contracture), -check for warmth, capillary refill (1)
Check pulse (1)
Student should ask for Vital signs (1)
Vital signs given to student on request =RR-22, P-115, T-37.4, BP-100/90
Check hepatic flap(1)
Head-conjunctiva-anaemia/jaundice, tongue-fetor (1)
JVP- (1)
Chest-Looking for peripheral liver disease stigmata(1)
Correct order for pain assessment: ask, point, cough(1)
Abdomen:
• Palpation, beginning in lower abdomen, away from site pain (1)
• Lightly palpate all 4 quads(1)
• Deeply palpate all 4 quads (1)
• Percuss abdomen gently 4 quads(1)
• Palpate Liver correctly (begin lower right quad) and percuss/measure(1)
• Palpate Spleen correctly(lower right quad and role patient)(1)
• Palpate kidneys (1)
• Palpate for AAA (1)
• Offer to Palpate groin-hernial orifices/scrotum/femoral pulses(1)
• Offer to peform DRE (1)
• Auscultate bowel sounds (1)
•
Lung: listening to lung bases (or saying they would but prefer not move
patient to due to pain)(1)
Describe how the examination findings support TWO most likely DDx
Pancreatitis (2)
Peptic ulcer (2)
Any of:
AMI (1)
Acute Cholecystitis (1)
Gastroenteritis (1)
Describe how the examination findings support TWO most likely DDx
Pancreatitis (2)
Peptic ulcer (2)
Any of:
AMI (1)
Acute Cholecystitis (1)
Gastroenteritis (1)
Technical skillsconsidering confidence, fluidity, systematic,
competency of examination technique.
Communication skills with the patient during the
examination, consider-introduction, consent, clear
instructions and empathy, awareness and
recognition for any patient discomfort
General feedback
Acute abdo-Examination station
• 2/41 students did NOT wash hands for examination stations
• Language-low confidence exhibited ’perhaps’, ‘possibly’,
‘maybe do’
• Warn pt re cold hands
• Review palpation technique-pushing in with fingers rather
than border index finger, palpating too lightly
• Doing dance and not seeing the signs
• If you state a differential diagnosis then need to address an
appropriate investigation
Acute Abdomen Examination
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DRE-not mentioned by 24/41
Vital signs not requested by 26/41
No check AAA by 32/41
No auscultation lung fields 26/41