OE EMQs

Question 1

Ocular signs associated with systemic diseases

• Reiter’s syndrome
• Syphilis
• Myasthenia gravis
  *

Answer 1

• Uveitis
• Argyll-Robertson pupil, where there is miosis and the pupil accommodates but does not react to light
• Ptosis

Question 2

Common skin infections

1. A 60-year-old obese patient with diabetes presents with a red, itchy, pustular rash in the sub-mammary folds, axillae and groin.
2. An elderly man presents with severe pain in the left thigh and inability to walk. Multiple vesicles in a linear configuration are seen over the anterior thigh.
3. A 30-year-old man presents with severe generalised itching which is worse at night. Both his wife and little baby are also scratching themselves.
4. A mother presents to the surgery with her three children. All three children have flesh coloured umbilicated nodules on their faces.
5. A 40-year-old man presents to his GP with a red, hot, swollen and painful leg. He admits to wounding the leg whilst gardening the previous day.

Answer 2

1. Candidal intertrigo favours warm, moist surfaces and is common in the obese as well as diabetics.
2. Herpes zoster is more common in the elderly and immunosuppressed. Severe pain limiting function may be the presenting complaint.
3. Scabies causes a generalised itch which is severe when the body is warm. It is transmitted by close contact and other members of the family have to be treated simultaneously. Papules, nodules, burrows and excoriations are found and areas most affected are the backs of the hands, genitalia and soles or palms in infants.
4. Molluscum contagiosum is a common viral infection transmitted by direct skin to skin contact, and therefore common in children and families. Lesions disappear spontaneously or after trauma, therefore scratching and picking result in resolution. In adults, multiple molluscum or genital molluscum are associated with HIV infection.
5. Cellulitis is a common skin infection and usually follows a discernible wound, for example, minor trauma or tinea pedis.

Question 3

Common Alcohol problems

Answer 3

1. hepatic encephalopathy
2. delirium tremen
3. intoxication

Question 4

Night blindness and beriberi are caused by what deficiency?

Answer 4

Vit A and thiamine

Night blindness and beriberi are diseases that usually affect people in developing countries; they are caused by vitamin A and thiamine deficiency respectively. Dry beriberi can to progress to Wernicke-Korsakoff, but in developed countries the syndrome is associated with alcoholism.

Question 5

classic presentation of PMR

Answer 5

Weight loss, fatigue and headaches

Question 6

Reactive arthritis (Reiter’s syndrome) is associated with…

Answer 6

urethritis, arthritis and iritis/uveitis. It is typically associated with a prior history of either urethritis or diarrhoeal illness. The disease typically affects young males.

Question 7

Patients who have fibromyalgia tend to be middle-aged women who have a history of

Answer 7

depression

Question 8

Sclerodactyly describes…

Answer 8

the tight skin over the fingers. As well as being a feature of diabetes, it is also seen in scleroderma.

Question 9

1. An autosomal dominant anaemia that is caused by a red cell membrane defect.
2. An autosomal recessive anaemia affects the haemoglobin, causing it to polymerise at low oxygen saturations, leading to severe muscle pain from blood vessel occlusion.
3. This acquired haemolytic anaemia can be classified into ‘warm’ and ‘cold’ sub-classes.
4. This mechanical haemolytic anaemia can occur in malignant hypertension or eclampsia.
5. This X linked recessive anaemia occurs with a defect in pentose phosphate pathway.

Answer 9

1. Hereditary spherocytosis
2. Sickle cell anaemia usually affects people of black African descent. The polymerisation of the haemoglobin causes occlusion of the blood vessels leading to the symptoms.
3. Autoimmune haemolytic anaemias can be sub-typed into ‘warm’ and ‘cold’. Warm and cold describe at what temperatures the antibodies against the RBCs best work.
4. Microangiopathic haemolytic anaemia.
5. Glucose-6-phosphate dehydrogenase deficiency

Question 10

Complications of Chronic Renal Failure

Answer 10

• pruritus. Can be treated by UV phototherapy.
• Anaemia, Due to erythropoietin deficiency.
• encephalopathy, Associated with a flapping tremor.
• Osteodystropy, Associated with failure of 1 alpha-hydroxylation of cholecalciferol.
• Dialysis dementia, Associated with accumulation of aluminium.
• dyslipidaemia is common in CRF and is due to impaired lipoprotein lipase activity with combined hyperlipidaemia.
• Gout is a common problem in patients with chronic renal failure.
  *

Question 11

Dressler’s syndrome

Answer 11

This is a pericarditis that develops two to 10 weeks after a myocardial infarction or heart surgery.

Question 12

XO genotype is associated with

Answer 12

Turner’s syndrome

• Short stature
• Failure of pubertal development
• Wide carrying angle
• Web neck
• Possible cardiac defects, such as coarctation.

Question 13

Klinefelter’s syndrome is

Answer 13

one of the commonest causes of elevated LH/FSH with low testosterone. There is absence/paucity of secondary sexual characteristics, the patient is often tall, has small testes and there is often reduction in IQ.

Associated with a 47 XXY karyotype.

Question 14

A congenital condition in which obesity is associated with mental retardation.

Answer 14

Prader-Willi syndrome

Obesity associated with hypogonadotrophic hypogonadism and mental retardation.

Question 15

Hypothalamic gonadotrophin releasing hormone deficiency with anosmia.

Answer 15

Kallmann’s syndrome

Kallmann’s syndrome is a common cause of hypogonadotrophic hypogonadism associated with failure of development of the olfactory bulbs hence anosmia.

Question 16

the two commonest causes of acute pancreatitis

Answer 16

Alcohol and gallstones

Question 17

Acute cholecystitis is distinguished from biliary colic in that there is …

Answer 17

no acute inflammation associated with the latter and so there is no pyrexia or peritonism and no elevated WBC/CRP.

Question 18

Charcot’s triad

Answer 18

jaundice, pain and fever

Question 19

Theme:Head and neck swellings
A Branchial cyst
B Carotid body tumour
C Cystic hygroma
D Lymphoma
E Parotid adenolymphoma
F Parotid pleomorphic adenoma
G Submandibular duct calculus
H Submandibular tumour
I Thoracic outlet syndrome
J Thyroglossal cyst

Question 20

commonest parotid tumours (75%)

A 63-year-old woman is referred with a longstanding and slow growing painless swelling overlying her left mandible. On palpation the lesion is firm and non-tender, and there is no facial nerve damage evident.

Answer 20

Pleomorphic adenomas

They typically have a smooth edge and irregular surface. They should be excised carefully taking care not to rupture the tumour as it can seed and regrow. Pleomorphic adenomas have a small risk of malignant transformation if left long term.

Question 21

Carotid body tumours usually present as

Answer 21

painless masses but occasionally may compress the vagus or hypoglossal nerves causing dysphagia, hoarseness, stridor, or weakness of the tongue. They are more common in people living at high altitude.

Question 22

A 76-year-old man is seen with multiple non-tender masses on both sides of his neck. He also reports weight loss, lethargy and night sweats. The lesions have a rubbery consistency and vary between 2 and 4 cm in diameter.

Answer 22

Patients with lymphadenopathy and constitutional symptoms must be regarded as having a lymphoma until proven otherwise. All head and neck lymphadenopathy must undergo FNA to exclude a squamous carcinoma prior to excision. However, FNA is often inadequate for diagnosis of lymphoma and an excision biopsy is required for characterisation of lymphoma and planning of chemotherapy.

Question 23

A 68-year-old male hypertensive smoker presents with sudden painless loss of vision in one eye. Fundoscopy reveals a pale retina with a cherry red spot at the macula.

Answer 23

Central retinal artery occlusion causes pallor of disc and retina, the macular is spared as it receives branches from the post ciliary artery. The occlusion is commonly atherothrombotic embolus. There is dramatic loss of vision within seconds`

Question 24

A 83-year-old female with a past medical history of angina, presents with sudden painless loss of vision in one eye. Fundoscopy reveals a hyperaemic retina with engorged veins accompanied by multiple haemorrhages

Answer 24

Central retinal vein occlusion is commoner than central retinal artery occlusion. Its causes include chronic simple glaucoma, arteriosclerosis, hypertension and polycythaemia. There is sudden loss of vision and the fundus looks like a stormy sunset.

Question 25

A 71-year-old male presents to his GP complaining of a gradual deterioration in his vision. In particular he has noticed that buildings do not appear straight. On fundoscopy there is pigment, exudate and bleeding at macula

Answer 25

Age related macular degeneration (ARMD) is the commonest cause of blindness in the United Kingdom. There is degeneration of central vision. The presence of drusen precedes the ARMD fundoscopic appearance.

Question 26

A 20-year-old male presents with difficulty night driving. Examination of his fundus reveals pigmentation at the periphery.

Answer 26

Retinitis pigmentosa is the most prevalent inherited retinal degeneration condition. There are many forms of the disease. Most are sporadic but may be inherited autosomal dominantly, autosomal recessively or X linked. Autosomal dominant forms have the best prognosis and X linked the worst. The onset is gradual and insidious and the most common complaint is difficulty with night vision although the presentation varies. It has associations with: ## Footnote Usher syndrome (retinal dystrophy and hearing loss) Congenital renal diseases such as renal-retinal dysplasia and Alport disease Neuronal diseases Enzyme deficiencies Mitrochondrial disorders.

Question 27

The only carcinoma provided here that is associated with clubbing is

Answer 27

bronchial carcinoma.

Question 28

A 69-year-old male presents with a six month history of 10 kg weight loss. He is a smoker of 10 cigarettes/d and has a history of hypertension. On examination, he is thin and has a palpable left supraclavicular lymph node.

Answer 28

This man has an enlarged Virchow's node and hence Troisier's sign - suggestive of gastric carcinoma

Question 29

Courvoisier's law

Answer 29

* the presence of an enlarged gallbladder which is nontender and accompanied with mild jaundice, the cause is unlikely to be gallstones. Usually, the term is used to describe the physical examination finding of the right-upper quadrant of the abdomen. This sign implicated possible malignancy of the gall bladder or pancreas and the swelling is unlikely due to gallstones.[1][2]

Question 30

Prehn's sign

Answer 30

Negative Prehn's sign indicates no pain relief with lifting the affected testicle, which points towards testicular torsion which is a surgical emergency and must be relieved within 6 hours. ## Footnote Positive Prehn's sign indicates there is pain relief with lifting the affected testicle, which points towards epididymitis.

Question 31

Virchow's node Troisier's sign

Answer 31

The finding of an enlarged, hard node (also referred to as Troisier's sign) has long been regarded as strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels.

Question 32

A flapping tremor/asterixis is caused by the three failures: ## Footnote

Answer 32

Liver Lungs Kidneys.

Question 33

A 79-year-old man has a six month history of rapidly progressive memory impairment. He has also had bradykinesia and rigidity, which was not responsive to co-beneldopa (Madopar) and has recently become very aggressive to his wife.

Answer 33

Lewy body dementia ## Footnote This patient has Lewy body dementia hallmarked by the presence of Lewy bodies within the brain stem and neocortex. There are features of parkinsonism which fail to respond to therapy and fluctuating cognitive loss.

Question 34

Left-sided colon cancer is more likely to present with

Answer 34

obstructive symptoms. Examination may be normal in early disease or reveal: ## Footnote Cachexia Abdominal tenderness Hepatomegaly Distension Ascities Rectal mass Blood in late disease.

Question 35

Bronchiectasis is due to

Answer 35

abnormal dilation of the proximal and medium sized bronchi. There are many causes: ## Footnote Infection Obstruction Cystic fibrosis Ciliary dyskinesia Young syndrome Allergic aspergillosis Alpha1-antitrypsin deficiency Autoimmune diseases such as Rheumatic arthritis Ulcerative colitis. It classically presents as cough with large amounts of mucopurulent sputum, sometimes blood streaked. Haemoptysis may be present. Patients often have clubbing and cyanosis with crackles and wheezing may be heard on auscultation. Antibiotics and physiotherapy are the mainstay of treatment.

Question 36

A 35-year-old international aid worker complained of feeling generally unwell with right sided abdominal pain, shivering and night sweats. He has a high swinging temperature and is tender in the right upper quadrant. A single mass is palpated in the right liver lobe, revealed to be cystic in nature on ultrasound scanning. His white cell count is elevated but liver function tests are normal.

Answer 36

An amoebic liver abscess is the most likely cause of a swinging temperature and a cystic liver mass. There is no history of diarrhoea in a half of cases. Liver function tests may be normal or show a cholestatic picture.

Question 37

An asymptomatic 55-year-old woman is investigated for a persistently raised alkaline phosphatase level. Her AST and ALT are only mildly elevated. On examination she has tendon xanthomata, and a smooth liver edge is palpable 3 cm below the costal margin. Her IgM is raised; results from auto-antibody screening are awaited.

Answer 37

Primary biliary cirrhosis is often asymptomatic and diagnosed after finding a raised alkaline phosphatase on routine testing. Xanthomata, hepatomegaly and a raised IgM are features of this autoimmune disorder. Antimitochondrial antibodies are usually positive.

Question 38

Tietze’s syndrome is a

Answer 38

benign condition of unknown aetiology consisting of non-specific inflammation and swelling of one or more costal cartilages. The resulting discomfort may be similar to pleuritic pain but local tenderness is elicited on palpation of the lump. Treatment is conservative, with local corticosteroid injection if necessary.

Question 39

A 57-year-old woman presents to her GP with a continuous ache on the right side of her chest. She also admits to weight loss and haemoptysis and volunteers that her right eyelid has recently begun to droop.

Answer 39

This lady has a right apical bronchogenic carcinoma (Pancoast’s tumour). Horner’s syndrome (ptosis, meiosis, anhydrosis and enophthalmos) has occurred as a result of neoplastic infiltration of the sympathetic outflow.

Question 40

A 17-year-old student presents in the Emergency department with increasing shortness of breath on exertion. On examination he is very thin and has signs consistent with a large right pleural effusion. Abdominal examination reveals 5 cm hepatomegaly and a hard irregular mass in the left side of the scrotum.

Answer 40

This young man has signs consistent with a left testicular carcinoma with distal metastases in the liver and lungs. Urogential tumours (that is, renal, gynaecological and testicular) classically cause multiple large pulmonary metastases known as 'cannonball metastases'.

Question 41

A 19-year-old man presents to his GP with a two day history of shortness of breath on exertion and a non-productive cough. He has felt non-specifically unwell with a headache for several days. Clinical examination is normal but a chest x ray shows patchy shadowing of both lower lobes.

Answer 41

Mycoplasma pneumoniae is one of the principal causes of atypical pneumonia. ## Footnote Non-specific symptoms, such as headache, diarrhoea and fatigue, tend to precede chest symptoms and at presentation chest x ray often shows consolidation before auscultatory signs become apparent. M. pneumoniae is notable for causing a wide range of extra-pulmonary conditions, including erythema multiforme and cold agglutinin production leading to haemolytic anaemia. There is also a strong association with Guillain-Barré syndrome.

Question 42

A 64-year-old man with a six month history of weight loss, constipation and rectal bleeding presents to his GP with shortness of breath and pleuritic chest pain which came on suddenly during a meal. Chest examination was normal.

Answer 42

This man has a history suggestive of colorectal tumour. He is therefore at risk of developing deep venous thrombosis, both as a result of direct venous compression by the tumour and also because of the pre-coagulant effect associated with carcinomatosis.

Question 43

The diagnosis of sarcoidosis is based on

Answer 43

the non-specific symptoms of weight loss and malaise coupled with a history of polyuria which is suggestive of hypercalcaemia, a common feature of active sarcoid. A maculopapular or vesicular rash on the face occurs frequently and if it becomes chronic and granulomatous, is termed 'lupus pernio'. ## Footnote Sarcoidosis is a multi-system granulomatous disease and in cases of insidious onset the presentation may therefore reflect involvement of any organ. More commonly however, the onset is acute and is characterised by erythema nodosum and bilateral hilar lymphadenopathy on chest x ray which is often associated with varying degrees of dyspnoea and non productive cough.

Question 44

Cryptogenic fibrosing alveolitis (known as idiopathic pulmonary fibrosis in the USA) generally presents in t

Answer 44

he sixth decade of life. Respiratory symptoms, other than progressive dyspnoea and dry cough, are uncommon. The classic examination findings are digital clubbing and fine end-inspiratory bibasal crackles.

Question 45

One major side effect of metformin is

Answer 45

lactic acidosis. This may be severe in situations of tissue hypoxia and in conditions such as renal impairment, alcohol abuse, liver disease and heart failure.

Question 46

Fluoxetine when given in combination with xxx increases the risk of xxx

Answer 46

sulphonylureas hypoglycaemia

Question 47

A 26-year-old female presents with a two month history of severe headaches that appears to be relieved by standing. On examination, it is noted that she is obese. She has no neurological abnormalities or visual disturbances.

Answer 47

Benign intracranial hypertension is a problem that more commonly is seen in young obese women. The patients may also have papilloedema.

Question 48

A 67-year-old lady presents with a three week history of intermittent facial pain. She says that the pain starts just in front of the right ear and spreads down toward the mouth. It is a sharp, stabbing pain that comes on intermittently - especially when she is out in the cold. There are no obvious signs on examination.

Answer 48

Trigeminal neuralgia is a relatively common problem that is mostly seen in patients aged over 60. It is characterised by sharp facial pain that comes on suddenly and the pain is in the distribution of the trigeminal nerve. The pain is usually brought on by a trigger such as cold air/chewing/cleaning teeth. The treatment is usually with pain relief and surgery.

Question 49

A 52-year-old male presents with a one month history of episodic headache. The pain is left sided and is described as "boring in one eye"; it can then spread to his forehead. He usually gets these episodes at night, a few hours after going to sleep. There are no obvious abnormal signs on examination.

Answer 49

Cluster headache is characterised by an intense pain that is concentrated around one eye. The attacks are more common at night and most commonly affect males aged over 40 years.

Question 50

The risk factors for developing pulmonary embolisms include ## Footnote Possible features include

Answer 50

Increased age Obesity Malignancy Pregnancy Treatment with HRT or the OCP Immobility. Shortness of breath Pleuritic chest pain Haemoptysis Hypotension Tachycardia Dyspnoea A raised JVP.

Question 51

A sign that is often linked to vitamin D deficiency is

Answer 51

the ‘waddling gait’. The insufficient vitamin D leads to an initial hypocalcaemia. Over a longer period of time the deficiency can cause secondary hyperparathyroidism.

Question 52

A 55-year-old female presents with a two month history of fatigue and itchy skin. On examination, it is observed that she has yellow sclera and hepatomegaly. A blood test shows raised bilirubin and raised alkaline phosphatase. what antibody would be present?

Answer 52

Antimitochondrial antibodies ## Footnote Primary biliary cirrhosis is an autoimmune disorder of the bile ducts with in the liver. Over 90% of patients with primary biliary cirrhosis have antimitochondrial antibodies.

Question 53

A 30-year-old female who is 28 weeks pregnant presents with hyperpigmentation around the cheeks, eyes and forehead, giving a 'mask-like' appearance.`

Answer 53

Melasma ## Footnote This is also termed the 'mask of pregnancy'. Most pregnant women develop increased pigmentation of the skin, which improves spontaneously after pregnancy. Melasma is also associated with the combined OCP.

Question 54

A 62-year-old female presents with severe, sharp and episodic pain during swallowing. Involved cranial nerve

Answer 54

Glossopharyngeal ## Footnote This story is typical of glossopharyngeal neuralgia, a similar condition to trigeminal neuralgia but affecting the IX nerve. The episodic lancinating pain may be produced by swallowing.

Question 55

A 58-year-old female presents with weight loss despite an increase in her appetite. She also describes overwhelming heat intolerance. On examination she has a tremor and is very agitated. Initail treatment

Answer 55

Carbimazole ## Footnote The symptoms point towards hyperthyroidism and thus the treatment is carbimazole.

Question 56

A 50-year-old woman presents with increased weight gain and bruising on her skin. On examination her limb muscles are wasted, her skin is very thin and she has unusual facial hair. Treatment?

Answer 56

Surgery ## Footnote Symptoms point towards a diagnosis of Cushing's which is treated by removal of the cause, often a pituitary tumour.

Question 57

A 27-year-old woman comes to her general practitioner because she has had urgency of micturition for the past few weeks. Dipstick testing of urine is clear. The general practitioner notes that, two years previously, she had episodes of visual disturbance over a period of a few weeks; these resolved spontaneously.

Answer 57

Multiple sclerosis has a relapsing and remitting course in approximately 2/3 of cases.The visual disturbance may have been an episode of optic neuritis, and the urgency of urine is likely to be due to a spastic paraparesis caused by demyelination in the spinal cord.

Question 58

A 70-year-old man complains of a two month history of difficulty swallowing, weight loss and weakness. He is unable to protrude his tongue and has difficulty in formulating speech. There is no cognitive abnormality. There is twitching of the muscles of the forearm

Answer 58

Motor neurone disease Motor neurone disease presents with bulbar weakness and fasciculations are typical.

Question 59

A 78-year-old man with weight loss and change of bowel habit develops abdominal swelling.

Answer 59

Carcinomatosis peritonei

Question 60

A 32-year-old female complains of foul smelling vaginal discharge. Smear examination shows numerous squamous cells and clue cells.

Answer 60

Bacterial vaginosis. 'Clue cells' are irregularly bordered squamous epithelial cells whose cell outlines are obliterated by sheets of small bacteria. These suggest a diagnosis of bacterial vaginosis rather than Trichomonas, as with the latter motile flagellated organisms should be seen.

Question 61

A 22-year-old sexually active female complains of vaginal discharge and deep dyspareunia. Smear for gonococcus is negative.

Answer 61

This case has features of pelvic inflammatory disease with Chlamydia being the most likely infective agent and is treated with tetracyclines.

Question 62

A 25-year-old female complains of thick white vaginal discharge. She is obese, has a vaginal pH of 4 and urinalysis shows ++ glucose.

Question 63

A drug that may produce a rapidly progressive pulmonary fibrosis.

Answer 63

Amiodarone is an iodine-containing compound that tends to accumulate in several organs, including the lungs. It has been associated with a variety of adverse events. Of these events, the most serious is amiodarone pulmonary toxicity. Although the incidence of this complication has decreased with the use of lower doses of amiodarone, it can occur with any dose. Pulmonary toxicity usually manifests as an acute or subacute pneumonitis, typically with diffuse infiltrates on chest x ray. With early detection, the prognosis is good. Most patients diagnosed promptly respond well to the withdrawal of amiodarone and the administration of corticosteroids, which are usually given for four to 12 months. ## Footnote Amiodarone can also produce, liver failure, thyroid disturbances, heart block and skin photosensitivity. Liver function and thyroid function tests are required before treatment and then every six months. A chest x ray is required before treatment.

Question 64

A drug that often causes headache, especially when patients first start the medication.

Answer 64

Headache is a common side effect of nitrate therapy because of vasodilation. It is often transient at the start of treatment. Patients should be warned of this possibility to encourage compliance.

Question 65

A 50-year-old male presents with dyspnoea and orthopnoea. He has a three year history of diabetes mellitus. Examination reveals that he is pigmented (he has not been sun tanning) and he has ankle oedema.

Answer 65

Haemochromatosis causes cardiac failure, liver failure, diabetes and pseudogout. It is also known as 'bronze diabetes'. Diagnosis is confirmed by genetic testing (HFE gene) and serum ferritin or transferrin saturations.

Question 66

On examination the mass is painless, approximately 2 cm in diameter, hard, with an irregular surface and does not transilluminate. ## Footnote What is the most likely cause of the lump?

Answer 66

Teratomas The main differentiating factor here is the age of the patient. Teratomas are tumours that more commonly occur in patients of the age group 20-30 and seminomas in the age group 30-50.

Question 67

A 35-year-old man presents with recurrent nose bleeds and haemoptysis. On systematic enquiry, he reports having noticed blood in his urine recently. He has a nasal septal perforation and multiple nodules are seen on his chest x ray.

Answer 67

Wegener's granulomatosis is characterised by involvement of the upper respiratory tract, lungs and kidneys. It often starts with severe rhinorrhoea. Haemoptysis, haematuria and epistaxis with the presence of a nasal septal perforation point towards this diagnosis. A chest x ray usually shows single or multiple pulmonary nodules, or pulmonary infiltrates with cavitation.

Question 68

A 22-year-old man presents to the Emergency department following an accident at work. A piece of scaffolding fell from two metres above him and trapped his left leg. His peripheral pulses are present on arrival in hospital two hours after the accident. He is admitted for observation when he becomes hypotensive with a poor urine output.

Answer 68

Rhabdomyolysis

Question 69

A 35-year-old lady is receiving an elective blood transfusion for symptomatic anaemia secondary to menorrhagia. Her temperature rises to 38.8 degrees 45 minutes after start of the transfusion. She is shivering, but her pulse and blood pressure are stable and her breathing is normal.

Answer 69

Shivering and a temperature of less than 40 is a prominent feature of a non-haemolytic febrile transfusion reaction.

Question 70

A 45-year-old man admitted with injuries from a RTA complains of chest pain soon after starting an emergency blood transfusion. He appears agitated and flushed and his temperature is 42.3°C. He is tachycardic and his blood pressure is falling.

Answer 70

Acute haemolytic transfusion reaction ## Footnote This patient has all the features of an acute haemolytic transfusion reaction (temperature of greater than 40, chest or abdominal pain, tachycardia, hypotension, agitation, flushing). This may be due to ABO incompatibility.

Question 71

A 35-year-old man with chronic renal failure complains of proximal muscle weakness and middle back pain. x Ray of his back revealed vertebral bodies to be reduced in density and biconcave (cod-fish vertebrae).

Answer 71

Osteomalacia is caused by defect in vitamin D availability or metabolism, resulting in inadequate mineralisation of osteoid framework. Other radiological changes include Looser's zones (pseudofractures) which can progress to complete fractures, and bowing of long bones in advanced cases. There is associated proximal myopathy, with a waddling gait.

Question 72

A 45-year-old man presents with a two year history of recurrent flitting arthritis, and peripheral neuropathy. There is evidence of symmetrical erosive polyarthritis. He distinctly recalls being unwell at the onset with malaise, myalgia, lymphadenopathy and a painful rash over his thigh.

Answer 72

Lyme disease is a tick-borne spirochaetosis caused by Borrelia burgdorferi, transmitted primarily by Ixodes ticks. It is a multisystemic disease affecting skin, joints (can mimic rheumatoid arthritis), central nervous system (meningoencephalitis, peripheral neuropathy and lymphocytic meningoradiculitis) and heart (atrioventricular block, pericarditis, myocarditis and heart failure). Early disease is characterised by expanding burning/painful rash (erythema chronicum migrans), accompanied by lymphadenopathy, malaise, fever and myalgia. It is present in America, Europe (including UK, for example, New Forest in Hampshire) and parts of Asia.

Question 73

A 55-year-old man has a stooped question mark posture and back pain. Chest expansion is reduced. There is clinical evidence of apical lung fibrosis and aortic regurgitation.

Answer 73

Ankylosing spondylitis affects young adults (five times more common in men), presenting with insidious onset of back pain, early morning stiffness and radiological evidence of sacroiliitis. It is related to presence of HLA-B27 (90% Caucasians with AS are HLA-B27 positive). The radiological hallmark is sclerosis with bony bridging (syndesmophytes) between the vertebrae, and also ligamentous calcification. In advanced cases, there is the question mark posture (loss of lumbar lordosis, fixed kyphosis and compensatory extension of the cervical spine). Extra-articular manifestations include apical lung fibrosis, cardiac conduction defects, iritis, aortic regurgitation, traumatic fracture of rigid spine and secondary amyloidosis.

Question 74

A 27-year-old woman has an asthmatic attack at home, and arrives at hospital tired and drowsy. On examination, she was cyanosed with a silent chest. Treatment

Answer 74

Mechanical ventilation ## Footnote This patient shows signs of a life threatening asthma attack (exhaustion, agitation or reduced level of consciousness, cyanosis, silent chest, poor respiratory effort). The patient will need care in the intensive care unit, and probably ventilation.

Question 75

A 64-year-old woman, who has panic attacks and shortness of breath, is increasingly depressed. She feels that she cannot cope and is seriously contemplating suicide. Treatment

Answer 75

Referral to psychiatrist ## Footnote As the patient is suicidal, she will need assessment by the psychiatrist and possibly be sectioned under the Mental Health Act, should she refuse.

Question 76

A 50-year-old man presents with a right pleural effusion after oesophagectomy for carcinoma. Pleural aspiration yields a milky fluid.

Answer 76

Chylothorax is due to leakage of chylous fluid (fat transported as chylomicrons reach blood stream through this route) from the thoracic duct. Most cases are acquired through trauma surgery (for example, oesophageal resection or those requiring mobilisation of aortic arch), blunt/penetrating injury and malignant infiltration. The fluid is classically milky. It is important to distinguish from empyema. Presence of chyle is confirmed by examining fluid microscopically and fat staining of globules is positive.

Question 77

A 24-year-old in her first pregnancy presents to labour ward at 28 weeks with uterine contractions and pain, with a temperature and flu-like symptoms. She reports a three day history of leakage of clear fluid vaginally that has now become offensive.

Answer 77

Chorio-amnionitis most commonly presents following preterm prelabour rupture of membranes. The first signs are often maternal shivering and temperature.

Question 78

A 29-year-old Afro-Caribbean woman in her first pregnancy presents to labour ward at 26 weeks with a history of increasingly severe abdominal pain. There is no vaginal bleeding. On examination, the symphysis-fundal height is 34 cms and the uterus is focally extremely tender to palpation. She has been vomiting throughout the day.

Answer 78

Degenerating fibroid ## Footnote Fibroids are most common in Afro-Caribbean women. They can degenerate in pregnancy, causing pain, uterine tenderness, occasionally precipitating preterm labour. Treatment is supportive: rehydration, analgesia and if appropriate, antibiotics.

Question 79

A 72-year-old man complains of great difficulty in walking downstairs and occasional double vision. There are diminished eye movements on the right side where the eye is unable to move to the inferior and medial position. which cranial nerve?

Answer 79

Trochlear

Question 80

A 72-year-old woman presents with bilateral foot drop and spastic weakness with muscle fasciculation of her legs. Recently, she has been prone to having chest infections. Her tongue was wasted and fasciculating.

Answer 80

Anterior horn cell disease (motor neurone disease) ## Footnote Motor neurone disease is associated with degenaration of motor neurones, somatic motor nuclei of cranial nerves and within cortex. There are three patterns - progressive muscular atrophy, amyotrophic lateral sclerosis and progressive bulbar palsy. Diagnosis is often made on clinical grounds. Denervation can be confirmed on electromyography.

Question 81

A 55-year-old man complains of left shoulder pain and weight loss. There is evidence of miosis and partial ptosis of his left eye.

Answer 81

Brachial plexus lesion ## Footnote This patient has left Horner's syndrome from a Pancoast's tumour. Carcinoma at the apex of lung can erode the ribs and lower part of brachial plexus (C8, T1 and T2) causing pain in shoulder and medial surface of arm.

Question 82

A 65-year-old man is found to have hepatosplenomegaly, with widespread lymphadenopathy. His full blood count revealed anaemia, thrombocytopenia and leucocytosis, with lymphocytosis. There were smear cells on his blood film.

Answer 82

Chronic lymphatic leukaemia ## Footnote CLL occurs mainly in older people and is due to uncontrolled proliferation and accumulation of mature B lymphocytes (rarely T cells). Lymphocytosis: WBC \>15 ×109/L, of which 40% are lymphocytes. It leads to: Painless lymphadenopathy Hepatosplenomegaly Anaemia (autoimmune haemolysis/ bone marrow failure) Thrombocytopenia, and Infections (neutropenia with or without reduced immunoglobulins).

Question 83

A 37-year-old farmer presents with a gradual onset of malaise, headaches, myalgia and night sweats. He has lymphadenopathy and hepatomegaly. His chest x ray is normal. His 2-mercaptoethanol test is positive.

Answer 83

Elevated serum IgG detected by extraction with 2-mercaptoethanol (2-ME) is evidence of current or recent infection with brucellosis. The occupation should have been a clue. Brucella is Gram negative coccobacillus. Acute brucellosis has insidious onset with: ## Footnote Malaise Headache, and Night sweats. There is lymphadenopathy, hepatomegaly, splenomegaly (in severe infections) and sometimes orchitis, osteomyelitis, meningoencephalitis and endocarditis. Treat with tetracycline with rifampicin (or Septrin).

Question 84

A 70-year-old man is found lying on the floor at home by his neighbour. His balance has been poor for some time and he walked with a stamping gait. His Romberg test is positive

Answer 84

Sensory ataxia ## Footnote High steppage or stamping gait (walks with wide based gait, continuously looking at the ground, raising feet high in air before stamping them to the ground) indicates dorsal column loss, which conveys touch, vibration and proprioception. It may be due to tabes dorsalis (syphilis infection) or subacute combined degeneration of the cord (B12 deficiency).

Question 85

A 56-year-old woman presents with troublesome abdominal distention and bloating, relieved by defecation. She is often constipated with stools ribbon-like in appearance. Her weight remains stable. ## Footnote

Answer 85

Irritable bowel syndrome ## Footnote Irritable bowel syndrome is a form of functional bowel disease. It is characterised by abdominal pain relieved by defecation, or change in bowel habit with altered stool frequency/consistency with sensation of abdominal distension. The patient often looks well despite the frequent episodes of pain. In an older patient, irritable bowel syndrome is a diagnosis of exclusion, following gastrointestinal investigations.

Question 86

A 45-year-old man of no fixed abode presents with severe abdominal pain for the last three days. He also complains of vomiting large amounts of fresh blood prior to his admission. Examination shows that he is well perfused, with several laparotomy scars on his abdomen. His haemoglobin is 15.2 g/dl.

Answer 86

Munchausen's syndrome is more common in men than women. Patients repeatedly present with dramatic illnesses, which seem to require urgent medical or surgical intervention. They may submit to investigations or surgery, but may suddenly discharge themselves before treatment is complete. In this case, the presence of multiple surgical scars, together with absence of anaemia or hypovolaemic shock should raise some suspicion.

Question 87

A 73-year-old, previously fit male presents with difficulty ascending stairs. Abnormalities noted on examination are weakness of knee flexion, which is more pronounced on the left with some wasting of the quadriceps and diminished knee reflexes. He is noted to have glycosuria.

Answer 87

Diabetics amyotrophy This is a classical example of diabetic amyotrophy, with an asymmetrical wasting and weakness of the quadriceps in an elderly person. This may be the initial presenting feature of diabetes.

Question 88

A 53-year-old patient with type 2 diabetes complicated by angina and chronic renal failure complains of breathlessness. Investigations include serum creatinine - 298 iu/l, Hb - 10 g/dl. Treatment

Answer 88

Erythropoeitin ## Footnote Chronic renal failure results in defective erythropoesis. Considerable evidence exists supporting the benefits of erythropoetin in patients with chronic anaemia associated with chronic renal failure. Prior to commencing it is important to ensure that the patient’s iron levels are adequate.

Question 89

A 60-year-old vagrant presents with generalised itching. There is widespread excoriation marks on his trunk and arms, with linear tracts around his wrists and between his fingers.

Answer 89

Scabie Linear or curved tracts may contain mites, eggs or faeces. Sites include finger webs, wrists, elbows, ankles, genitalia and breasts. Treat with malathion or permethrin.

Question 90

A 29-year-woman developed an itchy scaly rash particularly over her wrists, with fine white streaks overlying lesions. Her buccal mucosa is lined with a lacy, white pattern.

Answer 90

Lichen planus Clinical picture of lichen planus, which may be caused by drugs (thiazides, gold, phenothiazines, quinidine, antimalarials, sulphonamides, b-blockers, penicillamine) or graft versus host disease.

Question 91

A 60-year-old man complains of being tired, lethargy and pruritus. He also has nocturia and polyuria, with nausea and vomiting. Examination revealed pallor, pigmentation and fluid overload.

Answer 91

Uraemic symptoms include fatigue, breathlessness, ankle swelling, anorexia, vomiting, nocturia and pruritus. Examination can reveal pigmentation, pallor and brown nails.

Question 92

An 84-year-old woman in a nursing home has been constipated for a week. Over the past few days she has become increasingly confused and incontinent. Investigation

Answer 92

Midstream specimen of urine

Question 93

A 64-year-old man has recently been started on tablets by his GP. He is brought to the Emergency department by his wife with sudden onset of aggressive behaviour, confusion and drowsiness. Prior to starting the tablets he was losing weight and complaining of thirst. investigation

Answer 93

Blood glucose

Question 94

Recognised associations of SAH include ## Footnote

Answer 94

Polycystic kidney disease Ehlers-Danlos syndrome and Coarctation of the aorta.

Question 95

A 28-year-old woman has been overweight since her teens, and is worried about further weight gain of 5 kg in the past year. She has had no periods for the last nine months. Pregnancy test is negative. She has had some facial hair over the moustache area for years, but now needs to shave often. She has been trying to get pregnant for the past 18 months. Her BMI is 30.

Answer 95

Polycystic ovary syndrome is characterised by amenorrhoea or oligomenorrhoea, obesity and hyperandrogenism which may present as hirsutism and increased testosterone.

Question 96

A 3-month-old baby boy is wheezy, coughing, cyanosed and breathless with intercostal recession.

Answer 96

Acute bronchiolitis is very common in infancy. In winter epidemics, respiratory syncytial virus infections are the commonest cause. Wheeze, cough, fever and respiratory distress are common. Chest x ray shows hyperinflation.

Question 97

A 2-year-old boy is very unwell. His temperature is 39°C and he is flushed, toxic, and unable to swallow his secretions.

Answer 97

Acute epiglottitis is due to Haemophilus influenzae type B infection. It is characterised by sudden onset, high fever, continuous stridor and drooling of secretions. Intravenous antibiotics, anaesthetic support are usually indicated.

Question 98

A 4-year-old non-immunised boy presents with bouts of coughing ending in vomiting. He has an absolute lymphocytosis.

Answer 98

Whooping cough is caused by Bordetella pertussis infection. Bouts of coughing ending in vomiting, especially at night and after feeding suggest the diagnosis. The characteristic whoop, forced inspiration through a closed glottis may or may not be present. Absolute lymphocytosis is common. Complications include CNS haemorrhages, rectal prolapse and bronchiectasis.

Question 99

Klinefelter's syndrome is characterised by

Answer 99

tall stature, gynaecomastia and below average intelligence. Karytotype is XXY and there is a primary hypogonadism with low testosterone and elevated luteinising hormone/follicle-stimulating hormone (LH/FSH) (primary testicular failure).

Question 100

A 65-year-old man is referred from the cardiology team after undergoing a coronary angiogram six hours previously. On examination he is haemodynamically stable but has a large pulsatile mass in his right groin.

Answer 100

A pseudoaneurysm (false aneurysm) unlike a true aneurysm, has a wall made up from surrounding tissue. They occur following: previous vascular surgery; vascular trauma; instrumentation, for example, cardiac catheterisation; and IV drug abuse. Many resolve spontaneously with time. Acutely, Doppler ultrasound-targeted pressure may be used +/- thrombin injection to promote thrombosis. Complications include local compression (veins/nerves), infection and rupture - in these cases surgery is required.

Question 101

A 65-year-old lady presents to her GP after complaining of a dull central chest pain, especially after eating, and regurgitating undigested food up to three hours after eating it.

Answer 101

Achalasia is a problem with the coordination of swallowing in the oesophagus and lower oesophageal sphincter.

Question 102

A 51-year-old female with a history of treatment for thyroid dysfunction, presents with a sore throat of short duration. Examination reveals swollen and painful fauces.

Answer 102

Agranulocytosis ## Footnote Carbimazole therapy may result in agranulocytosis and occasionally in an aplastic crisis.

Question 103

A 60-year-old male who has a six year history of chronic lymphocytic leukaemia presents with symptomatic anaemia. His investigations reveal warm agglutinins, high lactate dehyrogenase and low haptoglobulin levels.

Answer 103

Autoimmune haemolytic anaemia may complicate CLL. Warm agglutinins are IgG antibodies that react with protein antigens on the RBC surface at room temperature causing haemolysis.

Question 104

A 70-year-old man presents to clinic complaining of progressive bilateral hearing loss over the last year. He accuses his grandchildren of mumbling. Rinne and Weber tests are both normal. He has a hearing test, which reveals high frequency hearing loss.

Answer 104

Presbyacusis ## Footnote This man has presbyacusis or senile deafness. It is caused by a gradual loss of hair cells in the cochlea and a loss of neurones in the cochlear nerve. Usually the high tones go first.

Question 105

A 35-year-old woman has developed deafness in her left ear. It became noticeably worse during a recent pregnancy and her mother had premature deafness. On examination both TMs are normal, the Rinne test is negative on the left and the Weber test lateralises to the left side.

Answer 105

Otosclerosis ## Footnote Conductive deafness(bone better than air) with a normal eardrum, is otosclerosis until proved otherwise. It is more common in women and typically deteriorates in pregnancy.

Question 106

A 28-year-old man with mild learning disabilities presents to his GP with a six month history of worsening dysarthria. He also states that his limbs sometimes jerk uncontrollably. The GP notices a greenish-brown pigment at the periphery of the cornea.

Answer 106

This man has Wilson's disease, characterised by an accumulation of copper in the ## Footnote Liver Brain Kidney Cornea (Kayser-Fleischer rings) Bone.

Question 107

A 27-year-old man presents to his GP with a six month history of feeling depressed. He also states that recently he has experienced jerky movements flitting from one part of the body to another. His father experienced similar symptoms aged 30 and committed suicide.

Answer 107

This man has Huntington's disease. He is experiencing choreiform movements. It is autosomal dominant and his father had the condition and committed suicide.

Question 108

A 19-year-old woman is admitted to a psychiatric hospital thinking that everyone wants to kill her. Four days later she develops severe abdominal pain, pyrexia, vomiting and starts to fit. She is referred to the Emergency department where the nurses notice that her urine turns red/brown on standing.

Answer 108

This lady has acute intermittent porphyria. Psychiatric disturbances include: ## Footnote Delirium Depression Emotional lability Schizophreniform psychoses Hysteria.

Question 109

A 70-year-old man presents to his GP complaining of bright red blood on the outside of his stool over the last six months. He also complains of an incomplete sensation after evacuation of faeces.

Answer 109

Colorectal adenocarcinoma ## Footnote Presentation depends on the site, with left-sided tumours presenting with PR bleeding, altered bowel habit and tenesmus. Right-sided tumours present with anaemia, weight loss and abdominal pain.

Question 110

A 70-year-old lady presents with rash around the left ear and severe pain within that ear.

Answer 110

Ramsay Hunt syndrome due to herpes zoster affecting the distribution of the facial nerve. Pain is referred back to ear

Question 111

A 19-year-old man diagnosed with Marfan syndrome is admitted with sudden onset of right-sided chest pain and right-sided click audible on auscultation.

Answer 111

Pneumothorax ## Footnote Causes: May be spontaneous (usually in thin males) Chronic obstructive lung disease Asthma Trauma Carcinoma of lung Cystic fibrosis Marfan syndrome Ehlers-Danlos syndrome Mechanical ventilation.

Question 112

Complications of diabetes mellitus

Answer 112

A Amyotrophy B Autonomic neuropathy C Cataracts D Diabetic ketoacidosis E Distal symmetrical neuropathy F Hyperosmolar non ketotic hyperglycaemic state G Hypoglycaemia H Microalbuminuria I Necrobiosis lipoidica J Proliferative retinopathy

Question 113

A 28-year-old woman with a history of type 1 diabetes and previous Graves' thyrotoxicosis has had no periods for five months and presents with hot flushes. A pregnancy test is negative and thyroid function tests are normal.

Answer 113

Premature menopause ## Footnote Premature ovarian failure is due to autoimmunity and is associated with other autoimmune diseases such as type 1 diabetes, Addison's disease and autoimmune thyroid disease. The exact mechanism is not fully understood.

Question 114

A 24-year-old female complains of a six month history of irregular periods, acne and weight gain. On examination she is overweight with a BMI of 32 kg/m2 and has some mild brownish pigmentation over the neck and axilla

Answer 114

Polycystic ovary disease ## Footnote Obesity is a well recognised in PCO disease but would be less likely if the history had suggested proximal muscle weakness or even striae.

Question 115

A 78-year-old man's spouse complains that he is becoming aggressive and talking about their sexual life publicly. He has normal memory on testing.

Answer 115

Pick's disease ## Footnote The predominance of frontal features is suggestive of Pick's disease. Patients become increasingly disinhibited and socially coarse. At times they may be euphoric.

Question 116

A 32-year-old man presents with a one month history of offensive ear discharge from the left ear. Examination reveals a facial nerve palsy and there is an attic perforation of the tympanic membrane.

Answer 116

Cholesteatoma ## Footnote The presence of an attic perforation with ear discharge and facial palsy is indicative of a cholesteatoma.

Question 117

A 35-year-old man presented with hypertension and complained of tingling in his fingers. He had an enlarged tongue and prognathism. A glucose tolerance test was abnormal. ## Footnote

Answer 117

Acromegaly ## Footnote Acromegaly is classically described with an enlarged tongue, impaired glucose tolerance and carpal tunnel syndrome. Hypertension is associated.

Question 118

A 45-year-old woman with disproportionately long limbs presented with hypertension. Her blood pressure was different on both arms and lower in the legs.

Answer 118

Coarctation of the aorta ## Footnote When the blood pressure is different in both arms and lower in the legs, this is suggestive of coarctation of the aorta.

Question 119

A 40-year-old man post-thyroidectomy for medullary thyroid carcinoma presented with hypertension and complained of attacks of severe headache and palpitations. He was noted to have glycosuria.

Answer 119

Phaeochromocytoma is likely. It is associated with multiple endocrine neoplasia type 2 that can occur with medullary C cell tumours of the thyroid gland.

Question 120

A 45-year-old woman is referred with a lesion on her cheek. On examination you see it has an irregular surface with smooth sides, central umbilication and a crusty core.

Answer 120

Keratoacanthomas are benign lesions that are often mistaken for BCC/SCC. They occur as a result of hyperplasia of hair follicles and are most common in sun exposed areas. They tend to regress spontaneously over a period of six to 12 months without the need for any treatment.However,some experts consider them to be a variant of SCC,so they are often excised as thy cannot be reliably distinguished clinically.

Question 121

A 4-month-old baby boy is brought by his mother who is concerned that his scrotum is swollen and he is constantly crying. He was born at 32 weeks gestation. On examination there is no discolouration of the scrotum and the swelling is non-tender and fully reducible.

Answer 121

Indirect inguinal ## Footnote The description indicates an indirect inguinal hernia. Boys are more commonly affected, especially if premature. In children the defect is a patent processus vaginalis. These hernias pass through the deep ring along the inguinal canal and out through the superficial ring and may pass into the scrotum. They are the commonest of abdominal hernias. All patients with inguinal hernias should be offered a repair. In children this is a herniotomy whilst in adults a herniorrhaphy is performed.

Question 122

A 68-year-old man attends the clinic with a swelling closely related to his right iliac fossa terminal ileostomy. He had previously undergone an emergency total colectomy for toxic megacolon. On examination there is a soft reducible swelling with a positive cough impulse.

Answer 122

Parastomal hernias are probably under recorded and occur as a segment of bowel emerges alongside the stoma. For ileostomies, this often causes severe pain whilst for colostomies, the symptoms are more commonly related to poorly fitting appliances. The diagnosis can be confirmed with CT and the stomal hernia repaired.

Question 123

A 44-year-old lady with known inflammatory bowel disease presents with a large ulcerating lesion over the anterior shin of the right leg which has a blue overhanging necrotic edge. Her ABPIs are normal.

Answer 123

Pyoderma gangrenosum are recurring nodulo-pustular ulcers with a tender red/ blue overhanging necrotic edge, commonly affecting the legs, abdomen and face. It is associated with: ## Footnote inflammatory bowel disease acute leukaemia polycythaemia rubra vera autoimmune hepatitis Wegener's granulomatosis, and myeloma.

Question 124

A 32-year-old male presents with weight loss, fever and fatigue. He is diagnosed with AIDS.

Answer 124

Hairy leukoplakia ## Footnote

Question 125

Hepatocellular carcinoma

Answer 125

Alpha-fetoprotein is often elevated in patients with hepatocellular carcinoma. It is also found in non-seminomatous germ cell tumours of the gonads. Beta-HCG is a tumour marker that may be found in bronchial carcinoma. It is also found in choriocarcinomas.

Question 126

Ovarian carcinoma

Answer 126

Ca-125 is typically elevated in association with ovarian malignancy.

Question 127

A 42-year-old female presents to the surgical outpatient clinic with painful ulcers and abscess formation in her perineal region. On examination, there are few small abscesses and multiple skin tags in the region. The skin over the area is tender, red and indurated. She also reports similar problems in her inguinal regions and axilla.

Answer 127

Hidradenitis suppurativa is a chronic suppurative disease of the apocrine sweat glands characterised by recurrent ulcers, abscesses, sinuses and, occasionally, fistulas. It commonly affects the axilla, inguinal region, perineal region and the buttocks. Chronic, longstanding hidradenitis suppurativa leads to subcutaneous fibrosis, scarring and contractures. The management of this condition usually involves excision of all the affected area. The area could either be left to heal by secondary intention or covered with a skin-graft or local flap. It is not closed primary.

Question 128

GCS Eye opening ## Footnote

Answer 128

Spontaneous (4) On speech (3) On pain (2) None (1)

Question 129

GCS Best verbal response ## Footnote

Answer 129

Orientated (5) Confused (4) Inappropriate (3) Incomprehensible (2) None (1)

Question 130

GCS Best motor response ## Footnote

Answer 130

Obeying commands (6) Localising limbs to resist uncomfortable stimuli (5) Withdrawing from uncomfortable stimuli (4) Flexing (3) Extending (2) None (1).

Question 131

A 20-year-old student plans to travel to sub-Saharan Africa for at least one month. She is worried about malaria and would like the best protection available.

Answer 131

Mefloquine is preferable to chloroquine and proguanil in this part of the world, with very high risk of chloroquine-resistant falciparum malaria. ## Footnote It is contraindicated in pregnancy. Important side effects include neuro-psychiatric reactions (hallucinations, psychosis).

Question 132

There has been an outbreak of meningococcal meningitis at the local university hall of residence. A 19-year-old student is worried, as she shared a room with another girl, who is now critically ill with meningitis.

Answer 132

Rifampicin 600 mg BD for two days should be given to close adult contacts. Medical and nursing staff need not be given chemoprophylaxis, unless they have given mouth to mouth resuscitation.

Question 133

A 62-year-old woman presents with a left groin swelling. On examination the lump is lateral to the femoral pulse.

Answer 133

Lymph node ## Footnote Inguinal lymph nodes are frequently confused with an irreducible inguinal or femoral hernia. They are usually multiple and associated with constitutional symptoms of fever and malaise and may be an early manifestation of lymphoma. The surgeon can be confident that the lump is a lymph node if lateral to the femoral pulse as inguinal and femoral hernias are medial.

Question 134

A 7-year-old boy is admitted with haemarthrosis of his left knee. These episodes have been recurrent since his early years. His activated partial thromboplastin time is significantly prolonged but bleeding time is normal.

Answer 134

Factor VIII concentrate ## Footnote This boy suffers from haemophilia, probably A. This is inherited as a sex linked recessive condition seen in 1 per 10,000 male births. Minor bleeds are treated with desmopressin, which raises factor VIII levels. Major bleeds require factor VIII concentrate administration to raise levels to above 50%.

Question 135

A 70-year-old man with a prosthetic mitral valve is admitted to hospital with a two day history of bleeding per rectum and a INR of 6. He had been commenced on ciprofloxacin three days previously by his GP, to treat a urinary tract infection.`

Answer 135

Fresh frozen plasma ## Footnote The high INR (international normalised ratio is the patient's prothrombin time expressed as a compared to the control) points to a drug interaction between wafarin and ciprofloxacin. The treatment of choice to stop his bleeding is fresh frozen plasma, since it is vital that this patient remains anticoagulated. Vitamin K would take too long (days) to control this patient's bleeding tendency.

Question 136

A 72-year-old woman has recently undergone hip replacement. She is breathless and centrally cyanosed. There is a fourth heart sound, and the venous pressure is elevated to 8 cm above the sternal angle.

Answer 136

Acute pulmonary embolism ## Footnote This woman has had a pulmonary embolus suggested by the proximity to the orthopaedic surgery and right sided failure.

Question 137

Oligohydramnios and renal tract malformation.

Answer 137

Angiotensin-converting enzyme inhibitors (ACEis) are absolutely contraindicated in pregnancy being teratogenic in the first trimester with cardiac, renal and neurological abnormalities.It is also fetotoxic in the second and third trimesters.

Question 138

Defective ossification with mid-face hypoplasia, saddle nose and cardiac abnormalities.

Answer 138

Warfarin is teratogenic in the first trimester and is associated with defective ossification. Beyond the first trimester, it is occasionally used but is associated with an increased risk of fetal cerebral haemorrhage.

Question 139

Neural tube defects.

Answer 139

Anticonvulsants ## Footnote This is a typical effect associated with anticonvulsants including phenytoin, valproate (1-2%) and carbamazepine (0.5-1%). The risk may be reduced through taking folate supplements prior to conception. Other effects of phenytoin include the fetal hydantoin syndrome - orofacial defects and reduced intelligence.