2003 paper errors Flashcards
Management:
45 year old man with a 6 week history of intermittent tender swelling that occurs below the left side of his jaw often during meals but can occur even if he thinks of food. It disappears overnight. You find a 3 by 2cms firm mass with no other abnormal findings.
Sialogram
1) This patient has sialolithiasis. Salivary gland stones cause pain whenever the patient salivates (eating or thinking of food, like Pavlov’s dogs!). Stones are commonly found in the submandibular gland. At night time, there is less salivation accounting for the lack of pain. Diagnosis can be confirmed by facial radiographs but a small number of sialoliths may not be seen on the plain film due to low calcium phosphate content. In this case, sialography used in combination with CT will demonstrate the stone. A complication is the development of sialadenitis.
Management:
70 year old woman who complains of palpitations, intolerance to heat, diarrhoea & weight loss. You find an irregular goitre in her neck that moves up and down when the patient swallows. There is no stigmata of Graves’ disease.
Technetium thyroid scan
This is a case of toxic multinodular goitre. It is most common in older patients and is associated with head and neck irradiation and iodine deficiency. TSH is the initial screening test and if supressed, T4/T3 levels are measured. As the peripheral stigmata of Graves’ disease is absent, thyroid scan and uptake is indicated. I-123 is the preferred isotope but as this option is not given, Tc-99 can be used although there is a risk of false positive images. The scan will show multiple hot and cold areas consistent with areas of autonomy and areas of suppression. Definitive treatment is commonly given in the form of radioactive iodine.
Management:
55 year old woman who complains of dysphagia is found to have a 10cms in width & 5cms in height bilateral symmetrical non-tender nodular mass in the front of her neck. Investigations show that she is euthyroid.
Upper GI endoscopy
The bilateral mass in the last part of this question is a multinodular goitre which does not need a biopsy. The patient is euthyroid. If the nodule was unilateral, then a biopsy is essential to establish or exclude malignancy. However, her dysphagia needs to be investigated with an upper GI endoscopy.
Treatment:
An 84 year old man presented to A&E with profuse diarrhoea and lethargy for the past 4 days. Clinical findings include tachycardia, dry tongue and raised urea.
Intravenous saline
This patient has clinical signs of dehydration. IV saline is indicated for fast rehydration. Oral rehydration will be too slow for this patient’s clinical state and will literally be thrown down the toilet due to the patient’s diarrhoea.
Treatment:
A 57 year old mature science student developed profuse diarrhoea and abdominal cramps following a meal from a local takeaway. 2 days later stool culture confirmed salmonella and the patient remained unwell.
Ciprofloxacin
Most cases of Salmonella gastroenteritis are self-limiting and antibiotics should not be used. However, antibiotics are recommended for infants <3 months, those >50 as well as immunosuppressed patients and those with internal prostheses. The typical antibiotic course is 3-7 days and the first line option for Salmonella is ciprofloxacin. Antiemetics can also be given to those with severe N&V. IV fluids should only be given if the patient is unable to tolerate oral fluids due to N&V.
Treatment:
A 24 year old legal secretary presents with a 6 month history of abdominal discomfort, fluctuating diarhoea and constipation with bloating. She denies weight loss or a change in appetite. Examination was unremarkable
Antispasmodics
The fluctuating diarrhoea and constipation without symptoms suggestive of IBD make IBS a more likely diagnosis. IBS is a chronic condition with abdominal pain associated with bowel dysfunction and is a diagnosis of exclusion. The pain or discomfort may be relieved by defecation. Examination is usually unremarkable and the diagnosis is based on the patient’s history in line with the Rome Criteria. If the patient presents with any worrying symptoms, then these will warrant a more thorough investigation. Treatment depends on the patient’s predominant symptoms. Antispasmodics relieve abdominal pain or discomfort but do not affect bowel habit. Examples include peppermint oil and dicycloverine. Laxatives can also be used such as lactulose. Lifestyle and dietary modifications combined with reassurance remain the 1st line intervention for functional bowel disease. IBS is linked with stressful jobs such as working as a secretary and there is a female/male ratio of 2:1.
Treatment:
A 63 year old man who has recently had chemotherapy for bowel cancer is suffering from diarrhoea.
Codeine phosphate
Codeine phosphate is an opiate and will kill two birds with one stone by offering effective pain relief and treating the diarrhoea. Codeine is used for mild to moderate pain, diarrhoea and as an antitussive.
Investigation:
73 year old man was reviewed in the diabetic clinic. He was complaining of increasing tiredness & loss of appetite. His ankles had become more swollen over the last few weeks.
Plasma creatinine
Diabetic patients are at risk of diabetic nephropathy and need to have their plasma creatinine regularly checked to monitor renal function. Tiredness, loss of appetite, confusion and pruritis can all be subtle signs of worsening renal function.
Diagnosis:
A 45 year old doctor from Ethopia with a 6 week history of fever, drenching night sweats and a cough. He is a heavy smoker. On examination he is thin and looks unwell. He has nicotine stained fingers. Dull to percusion at the right upper zone with reduced breath sounds.
Pulmonary tuberculosis
This is pulmonary TB. The patient is from an endemic area and has presented with fever, drenching night sweats and a cough. There is also anorexia and examination findings are consistent with post-primary TB with apical consolidation.
Diagnosis:
A 50 year old Asian diabetic woman is admitted with increasing shortness of breath and ankle swelling. ECG shows inverted T waves in levels I, AVL and V4-6. Upper lobe blood diversion and bilateral pleural effusions are found on chest X-ray
Pulmonary oedema
CXR findings here are consistent with pulmonary oedema. Pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion may be seen. The patient is also in CCF with evidence of LV dysfunction (SOB) and RV dysfunction (ankle swelling).
Diagnosis:
66 year old woman with right leg ulcer dressed by district nurse for 2 months. On examination there is a tender warm lump in the right groin.
Reactive lymph node
The leg ulcer indicates that there is local inflammation. Reactive lymphadenopathy is common when there is infection or inflammation.
Diagnosis:
62 year old man with enlarging pulsatile mass in left groin. 3 days previously he had had a coronary angiogram.
False aneurysm
This is a false or pseudoaneurysm as it does not involve all layers of the arterial wall. This has resulted from arterial trauma during the angiogram. Most cases of false aneuryms are as a result of iatrogenic trauma. A haematoma has formed between the breached layers and the remaining intact artery, causing the lump, which is pulsatile as blood rushes through the artery.
Analgesia contraindicated post op:
An 85 year old who is known to be hypertensive & has mild impaired renal function presents with signs of dehydration & undergoes a laparotomy for small bowel obstruction.
Diclofenac
NSAIDS may impair renal function and provoke renal failure, especially in patients with pre-existing impairment. NSAIDs should be avoided if possible in these patients or used with caution at the lowest effective dose for the shortest possible time. The mechanism of damage involves reducing creatinine clearance.
NSAIDs are also contraindicated in asthmatics as it causes bronchospasm due to the accumulation of leukotrienes.
Analgesia contraindicated post op:
A 60 year old man with diarrhoea is transferred from another hospital for urgent femoral-distal bypass surgery & arrives with a heparin infusion in situ. His APTT is 2.4.
Epidural bupivacaine fentanyl
Epidurals are relatively contraindicated in anticoagulated patients. Insertion of the epidural needle may lead traumatic bleeding into the epidural space and with clotting abnormalities, the development of a haematoma which can lead to spinal cord compression. Coagulopathy, raised ICP and infection at the injection site are absolute contraindications. Relative contraindications include anticoagulated patients and those with anatomical abnormalities of the vertebral column. NSAIDs do not increase the risk of epidural haematoma.
Analgesia contraindicated post op:
A 65 year old man with a history of peptic ulceration requires an aortic aneurysm repair electively.
Diclofenac
NSAIDs inhibit COX which has the effect of reducing PGE2 levels. PGE2 plays a role in gastric cytoprotection by downregulating HCl production and increasing mucus and the production of bicarbonate. This leads to gastric irritation and ulceration. A PPI can be prescribed alongside NSAIDs or misoprostol can be used, which is a stable PGE1 analogue which mimics local PG to maintain the gastroduodenal mucosal barrier.
Management:
A 52 year old man with diabetes for 15 years. Recently found to have microalbuminuria. Glycosylated haemoglobin 7.2%. BP 150/85. Cholesterol 5.2mmol/l.
Blood pressure control
BP control with an ACE inhibitor is necessary to reduce progression of diabetic nephropathy. Microalbuminuria is the earliest detectable sign and indicates trace amounts of albumin not detectable with standard urinalysis. If untreated, microalbuminuria will progress to intermittent albuminuria and then to persistent albuminuria which is 5-10 years away from ESRF. The main contributor to the development of diabetic nephropathy is hypertension. Other contributors include poor glycaemic control and renovascular disease such as renal artery stenosis. It is important to test kidney function and urine regularly.
Diagnosis:
A 71 year old man who has had a MI 6 months ago presents with shortness of breath & fatigue. On examination, the JVP is raised. He has pitting oedema to the knees. There is tenderness in the right upper quadrant with a smooth liver edge at 5cm.
Heart failure
This patient has heart failure, which has possibly occured as a consequence of his MI. SOB indicates pulmonary oedema due to LV failure. The raised JVP, peripheral oedema and tender hepatomegaly indicates RV failure. Initial investigations should include ECG, CXR, TTE and bloods including BNP levels. First line treatment is with an ACE inhibitor which reduces morbidity and mortality. Salt and fluid restriction is also beneficial. All patients with chronic heart failure will also receive a beta blocker such as carvedilol. Other adjuncts include spironolactone, diuretics, hydralazine and a nitrate, and digoxin.
Cause of HTN:
A 59 year old man, body mass index 29, random blood sugar 12.5mmol/l, total cholesterol 5.2mmol/l, HDL cholesterol 0.75mmol/l, BP 162/105mmHg.
Metabolic syndrome (Insulin resistance/Syndrome X)
Metabolic syndrome incorporates insulin resistance, IGT, central obesity, dyslipidaemia and hypertension. Multiple criteria exist to define this syndrome. This is sometimes called Reaven’s syndrome. Treatment aims at lifestyle interventions with statins if these do not achieve desired LDL cholesterol levels. Other lipid-lowering drugs such a fibrates can also be considered. The risk of developing T2DM is up to 5 times higher in those with metabolic syndrome. Low dose aspirin may be indicated, particularly for those at a higher risk, due to the prothombotic state of metabolic syndrome. Other treatments that can be considered include orlistat and bariatric surgery. Those with insulin resistance may benefit from metformin, which will reduce the progression to T2DM in patients with IGT.
Diagnosis:
A 25 year old patient presents with 1 year history of painful scrotal swelling. On examination there is a hard smooth swelling of the right testis. It did not transilluminate. There was no cough impulse.
Teratoma
Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30. Radical orchidectomy and histology is the initial treatment in most cases.
Diagnosis:
64 yr old woman complaining of severe back pain for some weeks. For the last few days shehas been very constipated and has been vomiting for 24 hours. She has been a smoker for many years and has had 3 courses of antibiotics for chest infections over the last 3 months.
Hypercalcaemia
90% of hypercalcaemia is caused by primary hyperparathyroidism or cancer. Cancer is the likely cause in this woman. Malignancy can cause hypercalcaemia either by direct bony involvement leading to osteolytic lesions or paraneoplastic syndromes involving PTHrp release. The tumour is typically very advanced if hypercalcaemia is a feature. Less common causes include vitamin D overdose, hyperthyroidism, immobilisation, Paget’s and milk-alkali syndrome. The classic bone disease in hyperparathyroidism is osteitis fibrosa cystica which causes pain. Symptoms of high calcium include confusion, constipation, polyuria, polydipsia, depression, kidney stones and lethargy. This can be remembered by ‘stones, bones, abdominal groans and psychiatric moans’. The serum PTH level is elevated in primary hyperparathyroidism whereas it may be very low in malignancy due to negative feedback.
Management:
60 yr old man with stable angina is awaiting surgery. he is on the highest tolerated dose of beta blocker and CCB but is still symptomatic. BP is 170/95 mmHg
Long acting nitrates
Long acting nitrates such as isosorbide mononitrate or transdermal GTN is indicated as the patient is still symptomatic on beta blockers and CCBs. Appropriate nitrate-free periods will be needed to avoid tolerance. Severe hypotension may occur if combined with a phosphodiesterase-5 inhibitor.
Investigation:
An 80 year old man presents with severely painful feet with mottled and purple toes with black areas. He tells you that he has also had constant severe back pain for a few days.
CT scan
This patient has a dissecting aortic aneurysm which can be diagnosed with a CT scan showing the presence of an intimal flap. The CT scan should include chest, abdomen and pelvis to visualise the extent of the aneurysm. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. The aortic dissection has led to a cholesterol embolism. This can be diagnosed histopathologically with the finding of cholesterol crystals. The phenomenon where cholesterol is released from an atherosclerotic plaque is called ‘trash foot’. A highly technical medical term. This results in the mottled appearance of distal embolism associated with livedo reticularis. You can search the internet for some case reports of this phenomenon.
Investigation:
A 25 year old university student presents with a high fever. He has petechial rash, black areas on his toes and fingers. His BP is 70/50.
Blood cultures
This patient has sepsis. Sepsis is the presence of SIRS with a likely infectious cause. This patient’s profound arterial hypotension means he has severe sepsis (dysfunction of one or more organ systems). The patient being a young university student most likely has meningitis even though symptoms of headache, photophobia and neck stiffness are not mentioned. Hence, a LP would be performed but it is not the 1st test to order in a patient who presents with sepsis.
It is important in the first instance to obtain a blood culture immediately, and preferably before antibiotics are started. If this is bacterial meningitis, you would expect to see a raised WCC on the LP with elevated protein, normal/reduced glucose and predominantly neutrophils in the white cell differential. Early blood cultures allows you to either broaden your empirical antibiotic spectrum or narrow it in those with sensitive organisms. It is worth noting that in sepsis, the patient may have a low temperature <36. A source of infection should be sought unless it is immediately evident such as the signs and symptoms of pneumonia being present. Petechial haemorrhage is a sign of organ dysfunction although a petechial rash may be due to meningococcal septicaemia.
Investigation:
A 55 year old woman presents with painful joints, a purpuric rash on her arms and legs. Systems review reveals heamoptysis and ear pain. On examination you find black patches on her toes.
ANCA (anti-neutrophil cytoplasmic antibody)
This patient has sepsis. Sepsis is the presence of SIRS with a likely infectious cause. This patient’s profound arterial hypotension means he has severe sepsis (dysfunction of one or more organ systems). The patient being a young university student most likely has meningitis even though symptoms of headache, photophobia and neck stiffness are not mentioned. Hence, a LP would be performed but it is not the 1st test to order in a patient who presents with sepsis.
It is important in the first instance to obtain a blood culture immediately, and preferably before antibiotics are started. If this is bacterial meningitis, you would expect to see a raised WCC on the LP with elevated protein, normal/reduced glucose and predominantly neutrophils in the white cell differential. Early blood cultures allows you to either broaden your empirical antibiotic spectrum or narrow it in those with sensitive organisms. It is worth noting that in sepsis, the patient may have a low temperature <36. A source of infection should be sought unless it is immediately evident such as the signs and symptoms of pneumonia being present. Petechial haemorrhage is a sign of organ dysfunction although a petechial rash may be due to meningococcal septicaemia.
Diagnosis:
A 58 year old male has had increasing difficulty swallowing. He has lost 10kg in the past 2 months. Upper GI endoscopy reveals a nearly circumferential irregular & ulcerated mass in the mid oesophagus.
Squamous cell carcinoma
Dysphagia coupled with weight loss and the irregular shaped mass points to malignancy. Dysphagia occurs when there is obstruction of more than 2/3 of the lumen and presence indicates locally advanced disease. There may additionally be odynophagia. Men are twice as likely to develop oesophageal cancer. GORD, Barrett’s oesophagus, FH, tobacco and alcohol are all risk factors. The two main types are squamous cell carcinoma and adenocarcinoma. Tumours in the upper 2/3 of the oesophagus are SCC whereas those that lie in the lower 1/3 are adenocarcinomas. The main test to order is an OGD with biopsy. Treatment is either surgical resection or with chemo or radiotherapy alongside endoscopic ablation with or without stenting and brachytherapy.
Diagnosis:
A 50 year old man has a rapidly growing mass in the thigh. A biopsy shows spindles of malignant cells.
Sarcoma
A scarcoma is a solid tumour of CT. Treatment is based on stage and histology but usually involves surgical excision in the first instance. Pathology needs to be reviewed by an expert who has experience with sarcomas.
Investigation:
A fit 28 year old man comes for an insurance medical & is found to have microscopic haematuria & on abdominal examination is found to have 2 large masses about 20cms by 12cms in each flank.
Abdominal ultrasound
This sounds like ADPKD. There may be a FH of PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and SAH). Patients may have haematuria, palpable kidneys and symptoms of a UTI. Hypertension and flank pain are also commonly seen. Hepatosplenomegaly may also be found. A renal ultrasound is the first test to order when the diagnosis is suspected. If the ultrasound is equivocal, a CT scan can be done of the abdomen and pelvis.
