2004 paper errors

Question 1

Diagnosis:
A 47-year-old man was brought into A&E having fainted in a wine bar at 6pm. His Glasgow Coma Score was 3. He was pale, sweaty and looked grey. He normally took no alcohol but had been celebrating his promotion at work by holding a champagne party.

Answer 1

Hypoglycaemia

Heavy alcohol consumption decreases hepatic production of glucose, putting this person at risk of hypoglycaemia. This patient is suffering from hypoglycaemia which is present when glucose drops <3mmol/L. Symptoms include sweating, weakness, drowsiness, palpitations and anxiety.

Question 2

Diagnosis:
A 47-year-old male policeman was brought to A&E having become SOB suddenly. He now complains of palpitations, which he has never experienced before. Heart sounds are irregular but no murmurs are audible. He is a diabetic with hypertension.

Answer 2

Atrial fibrillation

Atrial fibrillation is an irregular atrial arrhythmia with a broad list of risk factors such as coronary artery disease, heart failure, hypertension, DM and thyroid disorders. This patient has two of these risk factors. AF affects some 5% of those older than 69 years old. The presentation of SOB and palpitations is consistent with the diagnosis and the irregular heart sounds suggests AF as the cause. ECG would show absent P waves, a fibrillatory baseline and irregularly irregular complexes. Most that present with acute AF do not need immediate treatment, unless they have developed haemodynamic compromise, which requires immediate DC cardioversion. Most will require medical therapy with drugs to control the ventricular rate, restore and maintain sinus rhythm and prevent the occurence of thromboembolic events. Do you know which drugs are used and are you familiar with treatment guidelines for this common condition?

Question 3

Reduce CVS risk:
A 77-year-old man, normal blood pressure, not diabetic, who has had 3 episodes of transient left sided weakness in the last month.

Answer 3

Aspirin therapy

A TIA is colloquially called a ‘mini stroke’ with symptoms typically lasting under an hour. An antiplatelet drug such as aspirin is effective secondary prevention if the patient is not already anticoagulated. The patient will be anticoagulated if they have a likely or known cardioembolic source such as AF. Clopidogrel is an alternative in those who do not tolerate aspirin.

Question 4

Reduce CVS risk:
A 54-year-old man, normal blood pressure, normal lipid profile, BMI 28, random blood sugar 15 mmol/l, fasting blood sugar 8.5 mmol/l.

Answer 4

Weight reduction and metformin therapy

This patient has DM. Symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0. First line intervention in this situation is diet and lifestyle advice and changes. Metformin will be added if there is no adequate response. In terms of this question, this option will reduce cardiovascular risk the most for this patient. Metformin is a biguanide and suppresses hepatic glucose production.

Question 5

Cause:

A 56-year-old lady with a long history of asthma develops bruising.

Answer 5

Corticosteroids

Side effects of corticosteroids are due to exaggerated normal physiological actions. This lady with a long history of asthma is likely either taking inhaled corticosteroids or on oral therapy. An inhaled corticosteroid is used if a patient requires their reliever more than twice a week. Smoking, current or previous, reduces the effectiveness of inhaled corticosteroids so higher doses may be needed. In asthma, they reduce airway inflammation and reduce oedema and mucus secretion into the airway. Bruising is a documented side effect. Other side effects include adrenal suppression with prolonged use of inhaled therapy, LRTIs, predisposition to osteoporosis, anxiety, depression, hyperglycaemia and cataracts. Can you classifiy the wide range of side effects of steroids?

Question 6

Diagnosis:
A 48 year old male stripper presents with bruising, infections and fatigue. Lab findings indicate a pancytopenia with low reticulocyte count. Bone marrow biopsy is done on which a definitive diagnosis is made.

Answer 6

Aplastic anaemia

This is aplastic anaemia characterised here with the pancytopenia (which is common, but diagnosis requires 2 cytopenias out of 3) and the presentation with infections (neutropenia), fatigue (anaemia) and bruising (thrombocytopenia). Risk factors include paroxysmal noctural haemoglobinuria, hepatitis and NSAIDs. If macrocytosis is seen, this may suggest an inherited syndrome such as Fanconi’s anaemia. The reticulocyte count here rules out haemolytic anaemia, which isn’t even an option on the list. The definitive diagnosis is made on biopsy of bone marrow which shows a hypocellular marrow with no abnormal cell populations and no fibrosis. Which conditions would there be abnormal cell populations or fibrosis on bone marrow biopsy?

Question 7

Diagnosis:
A 62-year-old man with a history of alcohol abuse presents with bilateral parotid hypertrophy, gynaecomastia, testicular atrophy and easy bruising.

Answer 7

Hepatic cirrhosis

Cirrhosis is the end-stage of chronic liver disease, in this case due to alcoholic liver disease. Cirrhosis results in hepatic insufficiency and portal hypertension. The bruising here is due to thrombocytopenia secondary to portal hypertension with resulting hypersplenism and sequestration. Complications of chronic liver disease include ascites, variceal bleeds, jaundice, hepatic encephalopathy, hepatorenal syndrome and the development of HCC. Signs include spider naevi, palmar erythema, telangiectasia, bruising, gynaecomastia, Dupuytren’s contracture, parotid swelling and a red tongue.

Question 8

Diagnosis:
A 45-year-old HCV positive Egyptian journalist presents with acute renal failure. He is complaining of increasing abdominal distension, pruritis, ankle oedema and weight gain. Serum albumin is low and there is hyponatraemia and thrombocytopenia.

Answer 8

Portal hypertension

HCV in this patient is causing hepatic cirrhosis which has decompensated resulting in ascites, secondary to portal hypertension. The hypoalbuminaemia is a sign of decreased hepatic synthetic function. Hyponatraemia is a common finding associated with ascites. It arises due to reduced protein synthesis and therefore a loss of colloid osmotic pressure and increased fluid loss from the intravascular compartment, stimulating ADH secretion. There is peripheral oedema here which is due to low albumin. The pruritis is due to reduced hepatic excretion of conjugated bilirubin and there may be accompanying jaundice too. The cause of his renal failure may well be hepatorenal syndrome in the context of his severe liver disease. His prognosis is poor.

Question 9

Diagnosis:
A 45-year-old woman complains of abdominal pain for several months. On examination she is jaundiced with a distended abdomen and skin telangiectasia.

Answer 9

Cirrhosis

Cirrhosis is the end stage of chronic liver disease which results in hepatic insufficiency and portal hypertension, causing this patient’s jaundice, a sign a decompensation. Jaundice is also seen here reflecting reduced hepatic excretion of conjugated bilirubin and there may be associated pruritis. Telangiectasia is a sign of chronic liver disease. Risk factors for cirrhosis include alcohol, IVDU, unprotected sex and blood transfusion. This gives us an insight into the causes which include chronic viral hepatitis (C, B with or without D) and alcoholic liver disease. Other causes include conditions such as Wilson’s disease, NAFLD, haemochromatosis, Budd-Chiari syndrome and drug induced such as amiodarone and methotrexate.

Question 10

Diagnosis:
83-year-old man with longstanding heart failure for which he takes Digoxin and diuretics. For the last 24 hours he has been vomiting and has passed very little urine. On examination he is pale and mildly dehydrated; examination of the abdomen is normal.

Answer 10

Uraemia

This patient has developed acute renal failure, probably associated with the longstanding CCF. Advanced heart failure will lead to depressed renal perfusion and ARF. The decreased urine output is a symptom and the vomiting here is caused by uraemia or a general build up of waste products. An acute increase in creatinine will be seen, commonly with hyperkalaemia, hyperphosphataemia and a metabolic acidosis. There may also be respiratory compensation for this. Treatment is largely supportive, managing, in this case, the heart failure, and correcting abnormalities like volume status and the metabolic acidosis. Dialysis may be required.

Question 11

Diagnosis:
34-year-old man has had vomiting 2-3 times a day for 3 days. He complains of severe crampy abdominal pain and blood stained watery diarrhea. On examination temperature 37.7˚C. Abdomen soft, complains of generalised tenderness. No masses/rebound/guarding.

Answer 11

Salmonella

The only option on the list which fits is Salmonella. This could obviously be E coli or Campylobacter too, for instance. This is infectious gastroenteritis and Salmonella is a common cause, pretty much able to contaminate any food. It is commonly linked to poultry, dairy items and undercooked eggs. It is self-limiting and diagnosis is on isolating the organism from a stool culture. Treatment is supportive with fluid and electrolyte replacement and antibiotics are generally used only for patients with risk factors for severe disease or those with extra-GI complications. This is not viral gastroenteritis for the reasons below:
Viral gastroenteritis often presents with mainly UGI symptoms like N&V more so than diarrhoea. It is on this basis that this is likely to be viral gastroenteritis caused by organisms such as rotavirus, norovirus and adenovirus. Staphylococcus aureus and Bacillus cereus also tend to cause mostly UGI symptoms and acts by preformed toxins, though these are not on the list of available options. The differentiation is made on studying the stool and identifying the organism.

Question 12

Diagnosis:
A 17-year-old man presents with a 6 hour history of sudden onset of severe left scrotal pains. The scrotum is red and swollen, the testis and epididymis are very tender.

Answer 12

Testicular torsion

This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. The main differential is epididymo-orchitis but a high index of suspicion is necessary and if there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is also fixed to the posterior wall.

Question 13

Diagnosis:
A 70-year-old man present with mild dysuria, urinary hesitancy and terminal dribbling. He also has bilateral testicular pain, swelling and tenderness of both testes and epididymis. His temperature is 37.50ºC.

Answer 13

Epididymo-orchitis

Generally speaking, younger males are more likely to have an STI whereas older men are more likely to have an infection with enteric organisms such as ESBL. He is mildly febrile with tenderness on-top of urinary symptoms which points towards epididymo-orchitis. A urethral swab should be sent for Gram stain and culture of secretions. A urine dipstick is also necessary combined with urine MC+S. Treatment involves bed rest, scrotal elevation, analgesia and antibiotics if indicated.

Question 14

Diagnosis:
A 25-year-old single mother of three children presents in respiratory distress. There is progressively worsening SOB, wheezing and cough over the last 2 days. When you examine her, there are faint breath sounds, HR 120, RR 30. She gives a 6 month history of cough and SOB which has every now and then woken her up from sleep.

Answer 14

Bronchial asthma

Progressively worsening SOB and the wheeze, which may like this case wake the patient from sleep combined with the long duration of symptions suggests asthma. This patient is having an acute exacerbation and needs to be treated for this, before commencing the appropriate stepwise chronic treatment on the BTS ladder. Whether this exacerbation is mild, moderate or severe is based on the patient’s % predicted PEFR.

Question 15

Diagnosis:
An 80-year-old woman is admitted from a residential home with a two week history of purulent sputum and pyrexia (38ºC). Examination reveals a constant wheezing in inspiration and expiration localised over the right lung base.

Answer 15

Inhaled foreign body

This is aspiration pneumonia. There are symptoms of pneumoia with pyrexia and purulent sputum, along with risk factors for aspiration in this elderly person who may have difficulties swallowing or altered mental status from, for example, dementia. The location of the wheeze is also consistent with this diagnosis as the RLL is the most common site due to the anatomy of the bronchial tree. Complications include abscess and empyema. Treatment is predominantly with antibiotics and supportive care.

Question 16

Diagnosis:
A 30-year-old man attends for a routine pre-employment medical. On examination of the cardiovascular system, the doctor finds a soft (grade 2/6) ejection systolic murmur at the apex. He has no previous cardiac or respiratory problems and has a normal pulse and BP.

Answer 16

Innocent murmur

This is a functional murmur which is not caused by a structural cardiac defect. Functional murmurs tend to be systolic, occuring in an otherwise healthy individual with no symptoms. They are also characteristically position dependent and soft in nature. Ones that occur in children tend to disappear as the child grows. Benign paediatric murmurs include Still’s murmur.

Question 17

Diagnosis:
A 60-year-old Irish woman comes to see you with a progressive one year history of shortness of breath and recent onset of PND. She has been previously well apart from Sydenham’s chorea as a child. She had 6 normal pregnancies. On examination she has plethoric cheeks, the pulse is rapid (110/min), irregular and small volume. BP 128/80 JVP normal. The apex is in the 5th intercostal space in the mid-clavicular line and tapping in nature. The 1st heart sound is loud and P2 accentuated. A low pitched mid-diastolic murmur is heard at the apex.

Answer 17

Mitral stenosis

Sydenham’s chorea (St Vitus Dance) are dancelike movements seen in rheumatic fever. The major criteria for rheumatic fever can be remember by CASES: carditis, arthritis, Sydenham’s chorea, erythema marginatum and subcutaneous nodules. Practically every single case of mitral stenosis is caused by rheumatic heart disease. The process tends to also cause regurgitation. This is characteristically a grade 1-2 low pitch murmur heard in mid-diastole which has a rumbling nature and there is no radiation. There can be an associated malar flush, tapping apex beat and a diastolic thrill palpable at the apex, in the 5th intercostal space in the MCL. The first heart sound is also characteristically loud and often this is the most striking feature on ascultation. It is a difficult murmur to pick up so if you are ever asked at this stage to spot this murmur, it will most likely be based on the loud S1.

Question 18

Diagnosis:
A 65-year-old man had an inferior myocardial infarct 10days ago. His initial course was uncomplicated. He suddenly deteriorates with acute left ventricular failure. On examination the pulse is regular 100/min and normal volume and character. BP 110/60. The apex beat is dynamic. There is a loud grade 3/6, apical pansystolic murmur which radiates to the axilla.

Answer 18

Mitral regurgitation

MR is loudest at the apex and radiates to the axilla and tends to be around grade 4. It is associated with a systolic thrill at the apex. TTE is the investigation of choice for diagnosis. Chronic MR is associated with a laterally displaced apex beat with LV dilatation. Mitral valve prolapse is a strong risk factor for development of MR.

Question 19

Diagnosis:

A 35-year-old woman has a 10-year history of low retrosternal dysphagia and painless regurgitation of food in the mouth.

Answer 19

Hiatus hernia

A hiatus hernia is where intraabdominal contents protrude through the oesophageal hiatus of the diaphragm. Risk factors inclyde obesity and high intra-abdominal pressure. The condition may be asymptomatic, or it may present with symptoms (which are non-specific) such as heartburn, dysphagia, pain on swallowing, wheezing, hoarseness and chest pain. A CXR is the first test done and may show an air bubble in the wrong place but barium studies are diagnostic and treatment depends on the symptoms and anatomy of the hernia. Hernias can be sliding or rolling (or mixed, or giant), uncomplicated or complicated by, for instance, obstruction and bleeding. Do you know the difference between a sliding and a rolling hiatal hernia?

Question 20

Diagnosis:
A 50 year old describes a 5 month history of heartburn and cramp-like chest pain relived by drinking cold water, both unrelated to food. There has also been intermittent dysphagia to both liquids and solids, regurgitation and weight loss of 2kg.

Answer 20

Achalasia

This is achalasia which is a motility disorder with loss of peristalsis in the distal oesophagus and failure of the LOS to relax in response to swallowing. This presents commonly with dysphagia to both liquids and solids, regurgitation and retrosternal chest pain, which can be slowly progressive over time. In structural obstruction such as cancer, dysphagia to liquids is uncommon unless the disease is very advanced. Retrosternal pressure experienced can be precipitated by drinking liquids but is eased by continuing to drink, and the pain may be relieved by cold water. This may wake the individual from sleep. A UGI endoscopy is needed to exclude malignancy as a cause of dysphagia. The diagnosis is established on manometry or barium studies. Treatment is symptomatic.

Question 21

Diagnosis:
A 40-year-old man returned from India 4 days ago and came down with fever. He went to his GP and got some paracetamol. His fever persisted, and he had a few bouts of diarrhoea and cough. He started getting drowsy and was admitted from casualty where his blood culture was taken. The next day the lab reported Gram negative bacilli seen on blood culture.

Answer 21

Salmonella typhi

Typhoid (or enteric fever) is a faecal-oral illness caused by Salmonella enterica, serotype S typhi, Salmonella enterica and S paratyphi. There are over 2500 serovars for S enterica. In this country, it is mainly from people who have returned from a country where it is endemic – India, for example, which has the highest incidence of this disease. Mexico should also ring alarm bells. The water supplies are not treated and sanitary conditions are dire which prompts transmission of this infection. Humans are the only known reservoir. The vaccine only offers moderate protection and does not protect against paratyphoid infection. This person has a high fever which is a hallmark of infection (sometimes in a step-wise manner) which is not responding to paracetamol (it persists) and blood culture (you need a big sample of blood for testing as count is usually low) shows a gram negative bacilli, and he has returned from an endemic region. The fever of typhoid classically increases incrementally until a persistent fever with temperature 39-41 is established. There are also typically flu like symptoms after onset of fever and cough. Remember that characteristic findings such as bradycardia and rose spots may not be present and indeed rose spots may not be easy to spot in those with dark skin. Rose spots are blanching red lesions reported in 5-30% of cases usually occuring on the chest or abdomen.
This patient needs antibiotics though the temperature will fall over about week. A third generation cephalosporin is indicated due to resistance to fluoroquinolones in the Indian sub-continent. If the sensitivity panel returns and shows that this organism is sensitive to all antibiotics then ciprofloxacin should be given.

Question 22

Diagnosis:
A 50-year-old man went for Hajj. He was vaccinated against hepatitis and Group C meningococci. He came back with a high fever and was admitted with neck stiffness and drowsiness. He had a lumbar puncture and blood cultures. Gram stain of cerebrospinal fluid showed Gram negative diplococci.

Answer 22

Neisseria meningitidis type B

This patient has meningitis. A big risk factor is crowding which occurs during Hajj. Commonly there will be a headache, fever and nuchal rigidity. There may also be an altered mental status, confusion, photophobia and vomiting. Kernig’s sign is uncommon but is positive when attempts to extend the leg are met with resistance when the patient is supine with the thigh flexed to 90 degrees. Another uncommon sign is Brudzinski’s sign and a petechial/purpuric rash, typically associated with meningococcal meningitis.

Question 23

Management:
A 80-year-old woman is admitted with vomiting. Her blood pressure is 120/80 mmHg, pulse rate 90/min, with warm peripheries. Plasma urea is 25 mmol/l, and creatinine 120 μmol/l.

Answer 23

Intravenous saline

This patient is very dehydrated

Question 24

Management:
A 20-year-old man has been involved in a road traffic accident and the ambulance has just arrived. He has severe left upper abdominal tenderness, blood pressure 80/60 and pulse 140/min.

Answer 24

Colloid

As mentioned, first line fluid resuscitation is with 0.9% saline.

Question 25

Management:
A 25-year-old woman is admitted semi-comatose. She has been complaining of increasing thirst and lethargy over the previous few weeks. BM stick result is 36 mmol/l. Blood pH is 7.10 with a HCO3- of 15 mmol/l.

Answer 25

Intravenous saline

Initial treatment of DKA aims at correcting severe volume depletion (the main problem), again with IV saline infusion at a rate of 1-1.5L for the first hour. When glucose reaches 11.1mmol, fluid should be changed to 5% dextrose to prevent hypoglycaemia.

Question 26

Management:
A 75-year-old man underwent an anterior resection for rectal cancer 48 hours ago. He now has a urine output of 25mls/hr, BP 110/80, pulse 90/min. His Hb is 7.9g/dl.

Answer 26

Blood transfusion

This patient has been given IV saline already as the initial choice for volume expansion. His anaemia and clinical state warrants a blood transfusion. 1 unit of blood raises the Hb concentration by 1g/dL. Commonly, transfusion begins with 2 units of packed RBCs and the patient response is monitored.

Question 27

Diagnosis:
A 50-year-old man is assaulted by being hit in the face and around the head with a club. He now has bilateral bruising around the eyes and over the mastoid process.

Answer 27

Base of skull fracture

This is a basilar skull fracture and a CT scan (superior to MRI), in this case with 3D reconstructions, will be useful. These patients have hit their head head. Basilar skull fractures have specific clinical features. Blood pooling from these fractures can cause periorbital bruising (raccoon eyes), brusing over the mastoid area (Battle’s sign) and bloody otorrhoea. There may also be CSF leak resulting in CSF otorrhoea or rhinorrhoea. A unilateral raccoon eye has an 85% positive predictive value for this diagnosis. Base of skull fractures can also affect cranial nerves leading to hearing impairment (due either to SN as a result of VII injury or conductive due to haemotympanum) and facial numbness or paralysis. These patients also need to have their GCS calculated. Treatment is primarily conservative although surgical intervention may be needed if there is associated CSF leak, intracranial pathology or CN deficit. RTAs are the second most common cause of skull fractures, the first being a fall from a height. There may also, like the first case, be a history of assault resulting in head trauma or even a gunshot to the head.

Question 28

Diagnosis:
A 69-year-old alcoholic man collapsed after an alcoholic binge and struck his head on the pavement. He now has a deteriorating Glasgow Coma Scale.

Answer 28

Subdural haematoma

Blood collects between the dura and arachnoid mater in a subdural haematoma. This condition can run a variable disease course. This man is at risk because he is an alcoholic and this question tells you he has fallen over and hit his head on the pavement. It is important in the examination to look for signs of trauma such as scalp abrasions and bruises. It is also important in the work up to calculate this patient’s admission GCS, which is deteriorating, possibly as a result of raised intracranial pressure from the SOL. A CT scan will also be indicated. A surgical opinion is indicated. Treatment includes twist-drill craniotomy with drainage (a bedside procedure where a hand drill is used to gain access to the subdural space and then a catheter is placed to act as a drain). Standard craniotomy is also an option, as is the creation of a burr hole. Unlike an extradural there is no ‘lucid interval’. Also extradurals tend to occur in younger patients, usually with an associated skull fracture, and CT of the haematoma does not cross suture lines.
In diffuse axonal injury, there will be a history of trauma involving shear or acceleration/deceleration force.

Question 29

Diagnosis:
A 20-year-old woman is assaulted in a nightclub. She suffered a short episode of loss of consciousness, double vision and has vomited once. She now has a headache.

Answer 29

Concussion

Concussion is a closed head injury due a blow to the head. This woman has been assaulted, which is a common cause. Typical symptoms include headache (which tends to be cause the most problems in management), mental slowness, memory difficulties, N&V and LOC, though LOC is not necessary for the diagnosis. Symptoms typically go after a week to a month but can fluctuate. CT and MRI are typically normal. For uncomplicated cases, resting is sufficient and no intervention is needed.

Question 30

The immediate management of an acute deep vein thrombosis in someone who is at a high risk of bleeding.

Answer 30

Unfractionated heparin

The mainstay of treatment for acute DVT is anticoagulation. This can be either unfractionated heparin, a LMWH or a factor Xa inhitor like fondaparinux. Fondaparinux has a higher half life than LMWH and there is no effective way of reversing it. LMWH have a shorter half life and some of it can be removed with protamine. Heparin though can be reversed quickly with protamine. Hence, if the patient is at a high risk of bleeding, they should be treated with unfractionated heparin and you should avoid fondaparinux. If they start bleeding you can just chuck them protamine. This however requires monitoring of APTT and platelet counts. If the patient has heparin-induced thrombocytopenia, you can try using fondaparinux. LMWH is recommended in those with active cancer and preferred in pragnancy, and consideration needs to be given in those with renal impairment.

Question 31

Management:

Disseminated intravascular coagulation.

Answer 31

Platelet concentrates plus fresh frozen plasma

DIC is a syndrome where coagulation pathways activate resulting in intravascular thrombosis, platelet and clotting factor depletion. The underlying disorder needs to be treated and FFP with platelet concentrate needs to be given. A platelet infusion should be considered and FFP is preferred for replacement of clotting factors and clotting inhibitors. Complications of DIC include life-threatening bleed, ARF and gangrene.

Question 32

Diagnosis:
A 40-year-old female has a routine blood test showing serum calcium 2.85 mmol/l (corrected). She takes no medications. PTH is also elevated and ALP is mildly raised. She is depressed.

Answer 32

Primary hyperparathyroidism

This is the most common cause of hypercalcaemia. 85% are due to a single adenoma in one of the glands while most of the rest are due to 4 gland disease. The range of disease is from very mild/asymptomatic through to severe disease with bone loss, fractures and osteitis fibrosa cystica. There is autonomous PTH production in primary HPT which causes deranged calcium metabolism. Biochemistry will show elevated serum calcium and inappropriate elevation of PTH. Depression, cognitive changes, change in sleep (possibly due to change in circadian rhythm) and myalgia are all common complaints. Osteoporosis may occur due to excess PTH causing bone resorption (osteoclasts are stimulated). Hypercalciuria may cause renal stones and nocturia. The only definitive cure is a parathyroidectomy although complications of this procedure include hypocalcaemia, injury to the recurrent laryngeal nerve, bleeding and a pneumothorax.

Question 33

Diagnosis:
A 55-year-old lady with a family history (mother) of death following hip fracture is obsessed with the risk of osteoporosis and has been purchasing large quantities of OTC medication. There is hypercalcaemia.

Answer 33

Vitamin D intoxication

This silly lady has self-over-dosed on vitamin D. This is a fat soluble vitamin which can be toxic when taken in excess over time. OD of alfacalciol or calcitriol can easily cause hypercalcaemia and this needs to be avoided. So why is this not milk-alkali syndrome? Milk-alkali syndrome is caused by excess milk, as the name suggests, or alkali, for example due to dyspepsia. Excess intake, or calcium supplementation OTC can lead to hypercalcaemia, so granted if she is buying lots and lots of chewable calcium carbonate or something this is possible, but it is more likely in post-menopausal women on supplementation - just think about what is more likely here. Also, the patient is not completely stupid and will not be OD on vitamin A, even though is a cause of hypercalcaemia.

Question 34

Cause of hypotension:
45-year-old man presented with severe chest pain radiating down his left arm. He was pale, cold and sweaty. BP was 80/50 mmHg, pulse rate was 100 and regular. JVP was raised by 3cm and auscultation of his chest revealed basal creps. Over the next few hours, he became progressively short of breath despite being given IV diuretics. Chest x-ray showed signs of pulmonary congestion.

Answer 34

Cardiogenic shock

Cardiogenic shock is pump dysfunction. This may occur, like in this case, after MI (shock complicates just under 10% of MIs) or may be due to cardiomyopathy, valve dysfunction or arrhythmias. This cause of shock in this patient is obviously apparent. Clinical signs of shock include stress responses of tachycardia and tachypnoea, hypotension (<90 systolic) with signs of hypoperfusion (for example, cold extremities). Raised JVP, basal crackles and pulmonary oedema support cardiac failure. Treatment begins with your ABCs. In this case, urgent revascularisation of the coronary arteries is indicated.

Question 35

Cause of hypotension:
67-year-old man was observed to be very drowsy 12 hours after an aortic aneurysm repair. There had been considerable blood loss and he had been given 4 units of blood during surgery. He had been written up for pethidine 50-100 mg 3 hourly postoperatively and had had 3 doses. BP had been 150/80 post-op and was now 100/60 with a pulse rate of 75/min. O2 saturation was low at 85%.

Answer 35

Drug induced

Opioid OD symptoms include CNS depression (drowsiness, sleepiness), respiratory depression and relative bradycardia. This patient needs ventilation prior to the administration of naloxone, titrated to patient response.

Question 36

1st investigation:

Pituitary tumour

Answer 36

MRI head

Pituitary MRI is preferred over CT and you will be able to see if the tumour has invaded, for example, the sphenoid sinus and cavernous sinuses or any compression of the optic chiasma. MRI is contra-indictaed in some cases such as those with a permanent pacemaker or those with ESRF on dialysis – in which case you would perform a CT. Both are done with contrast enhancement. A sellar mass will be seen.

Question 37

Diagnosis:
A 72 year old woman is being treated for a diabetic foot ulcer and is afraid she may need an amputation. Serum potassium today is markedly elevated. Results over the past week have been normal. You find out the 2nd year medical student had some difficulty drawing the blood.

Answer 37

Pseudohyperkalaemia

This is pseudohyperkalaemia caused by haemolysis of the sample. The medical student who has had some difficulty drawing the blood has haemolysed the sample. Potassium in serum will in this case exceed the plasma value by >0.5 mmol/L and the pink tinge when centrifuging the sample will also give this away.

Question 38

Diagnosis:
A 16 year old diabetic has been trying to lose weight. She presents at with a vomiting, postural hypotension and abdominal pain. She insists she has been taking her insulin regularly and does not use illicit drugs. Serum potassium is elevated.

Answer 38

DKA

This is DKA. This girl is simply lying about her insulin and has been skipping insulin doses in order to lose weight. This is known as ‘diabulimia’. The main thing that needs to be corrected is the severe intravascular volume depletion and to restore tissue perfusion with IV saline. Insulin will of course also be needed. When glucose reaches 11.1mmol, fluid should be changed to 5% dextrose to prevent hypoglycaemia. Insulin should be held until potassium is at least 3.3 mmol/L (remember insulin moves potassium into cells) and a continuous infusion is recommended (with new DKA treatment guidelines, the ‘sliding scale’ is now a thing of the past). If interested, look up the latest DKA treatment guidelines for more information.

Question 39

Ix:
A 32-year-old man attends your surgery saying he brought up blood every morning for the last week. He is unsure whether he is vomiting or coughing it up. His haemoglobin (done yesterday) is 14 g/dL.

Answer 39

Chest x-ray

The blood being brought up here occurs at a fixed time period every day and he is not anaemic. This makes you suspect a respiratory cause of his haemoptysis such as pneumonia – particularly TB, cancer, vasculitis like Wegener’s, bronchiectasis and bronchitis.

Question 40

Ix:
A 28-year-old woman with a carcinoma of the cervix was admitted with plasma creatinine of 250μmol/l. BP was 130/80. Urinalysis was negative.

Answer 40

Renal ultrasound

A patient with cervical carcinoma is at risk of ureteric obstruction and then hydronephrosis. Again ultrasound is the test of choice.

Question 41

Ix:
A 32-year-old man presents with oedema. Plasma creatinine 150 μmol/l, urea 15 mmol/l, albumin 15 g/l. Urine protein excretion 8.5 gm/24 hour. Routine immunescreen (antinuclear antibody, complement levels, CRP) is normal.

Answer 41

Renal biopsy

When the cause of renal failure might be nephritis (as in nephrotic syndrome) a renal biopsy will be needed to make the diagnosis. Occasionally this is urgent, so that potent immunosuppresives can be administered.

Question 42

Ix:
A 76-year-old man presents with lethargy and back pain. Plasma creatinine 220 μmol/l, urea 18 mmol/l, calcium 2.9 mmol/l (2.2 – 2.6), albumin 29 g/l. Urine protein excretion 1.5 gm/24 hours.

Answer 42

Plasma electrophoretic strip

Renal impairment in myeloma results from a combination of factors: deposition of light chains, hypercalcaemia, hyperuricaemia and (rarely) in patients who have had the disease for some time, deposition of amyloid. Serum protein electrophoresis characteristically shows a monoclonal band.

Question 43

Ix:
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.

Answer 43

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.

Question 44

Ix:
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.

Answer 44

Anti-neutrophil cytoplasmic antibody

This patient has Wegener’s granulomatosis, a systemic vasculitis affecting small and medium sized vessels. The classic triad includes upper and lower respiratory tract involvement and GN. Musculoskeletal manifestations such as arthralgia and signs of thromboembolism are commonly seen. A positive cANCA (antigen being proteinase 3) in the setting of the classic triad is sufficient to diagnose Wegener’s. Urinalysis and microscopy is also indicated to reveal renal involvement and a CT chest may reveal lung involvement, particularly in those who are asymptomatic for pulmonary involvement. This may show nodules or infiltrates.

Question 45

Ix:
An 80-year-old man with diabetes presents with black right great and second toes. He also has an ulcer on the ball of the foot.

Answer 45

Arteriogram

Diabetic neuropathy has lead to the painless ulcer developing over pressure points in the foot such as on the ball of this man’s foot. This may have resulted from an object becoming lodged in the shoe and eroding through the skin with walking. This is why it is important for diabetics to check their feet regularly and to wear specialised footwear. The black toes on his right foot are likely due to peripheral vascular disease. It is worth noting that peripheral vascular disease refers specifically to peripheral arterial disease. The first line study is an ABPI although an arteriogram can be done to identify areas of stenoses which can be treated surgically. The black mummified toes may have to be amputated.

Question 46

Ix:
A 25-year-old Sikh presents 3 months after arrival in the UK with anaemia and an enlarged spleen. He gives history of intermittent febrile episodes.

Answer 46

Thick blood film

In the Western world, almost all cases of malaria occurs in travellers so an adequate travel history is crucial or the diagnosis may be missed. Patients typically present with non-specific symptoms such as a fever, sweats, chills and myalgia. This Sikh may have just arrived from an endemic area. Sometimes EMQs will describe patterns of fevers occuring at regular intervals of 48-72 hours associated with P. vivax, P. ovale and P. malariae infections but in most patients there is no specific pattern. Hepatosplenomegaly is a common presenting sign, although in the Western world, it is not common on initial presentation.

The test of choice is Giesma-stained thick and thin blood smears. Thick films sensitively detect parasites whereas thin films allow species identification and calculation of parasitaemia to guide treatment. In this case, if you had to pick one, then the thick film would be more useful in establishing the diagnosis. Studies have shown that for P falciparum, the most effective treatment is artesunate which is more effective than quinine without the risk of cinchonism. However, not all hospitals are currently licensed to use it in the UK (in London, only the Hospital for Tropical Diseases and Northwick Park). Artesunate is manufactured by a pharmaceutical company in China and there are doubts over the quality of the product. However, there have now been numerous studies such as the AQUAMAT study in The Lancet showing that quinine should no longer be the established treatment of choice.

Question 47

Ix:
An 18-year-old African woman presents in A&E with severe right shin pain. She has had similar previous episodes. She is found to be anaemic.

Answer 47

Haemoglobin electrophoresis

Africans have higher incidence of sickle cell anaemia. This is a presentation of bone pain. About 8% of black people carry the gene and the prevalence is high in sub-Saharan Africa. Sickling occurs when RBCs containing HbS become distorted into a crescent shape. Patients with sickle cell anaemia have no HbA at all. If both parents carry the sickle cell gene, there is a 1 in 4 chance of giving birth to a child with sickle cell anaemia. Sickle cell disease also includes other conditions such as HbS from one parent with another abnormal Hb or beta thalassaemia from the other parent such as HbS-Beta thal and HbSC.

Question 48

Ix:
A 62-year-old man with chronic mechanical low back pain which has been treated with ibuprofen. He presents with bilateral ankle oedema and dyspnoea. He is found to have a haemoglobin of 7.2g/dL and has epigastric tenderness.

Answer 48

Upper GI endoscopy

This patient is anaemic due to a bleeding peptic ulcer which has resulted from prolonged NSAID use. Dyspnoea is a symptom here and the ankle oedema could be due to high output heart failure. The most specific and sensitive test is an upper GI endoscopy. Duodenal ulcers rarely undergo malignant transformation so do not require a compulsory biopsy but gastric ulcers require biopsies to rule this out. Management is aimed at correcting the underlying cause such as discontinuing NSAIDs in this case. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.

Question 49

Ix:
A 19 year old male medical student develops acute chest pain during a game of squash. On examination he is distressed there but examination is otherwise unremarkable. There is a family history of sudden death.

Answer 49

Transthoracic echo

This patient has likely HOCM. The patient’s young age makes it unlikely to be atherosclerotic coronary artery disease (unstable angina). HOCM is the most likely cardiomyopathy and the most frequent cause of sudden cardiac death in younger people. The FH of sudden death is suggestive of this diagnosis. This has a benign prognosis is most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion (playing squash) is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance.
Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. A fourth heart sound may also be heard due to hypertrophy. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echo will show septal hypertrophy. There may also be MR.

Question 50

Ix:
An 80 year old woman on corticosteroids develops acute chest pain while standing up. It is posteriorly sited, radiating anteriorly under the breast. The pain is worse on movement and there is tenderness on the back of the chest. Cardiovascular and respiratory examination are normal.

Answer 50

Thoracic spine x-ray

This patient likely has osteoporotic vertebral collapse/fracture which is compressing the intercostal nerve and causing her sudden pain in the back of her chest. The pain tends not to be related to traumatic activities and can occur on standing up or bending forwards, even coughing and sneezing. The history of corticosteroid use is associated with osteoporosis through multiple mechanisms. The thoracic spine plain x-ray would show loss of height in one of the thoracic vertebrae. Osteoporotic changes may also be seen such as osteopenia. Treatment depends on the extent of spinal involvement and the severity of the pain and whether it is complicated by spinal deformity such as kyphosis. For the diagnosis of osteoporosis, a DEXA scan is needed indicating a T score of less than or equal to -2.5.

Question 51

Diagnosis:
A 60-year-old woman presents with a poor appetite, weight loss, tiredness and intermittent right iliac fossa discomfort for the last six weeks.

Answer 51

Caecal carcinoma

The weight loss, fatigue and RIF discomfort point to caecal carcinoma. Right sided colorectal cancer tends to present with anaemic symptoms. Almost 90% are anaemic at diagnosis.

Question 52

Diagnosis:
A 68-year-old woman presents with a two day history of passing copious quantities of blood per rectum and a fever. She has also had left iliac fossa pain during this period.

Answer 52

Diverticular disease

Symptomatic diverticulitis presents with fever, high WCC and LLQ pain. There may uncommonly be rectal bleeding which is usually painless, profuse and arterial in nature. Risk factors for diverticular disease include low dietary fibre and advanced age. Oral antibiotic therapy and analgesia is indicated. If there is no improvement in 72 hours after oral antibiotics then IV antibiotics are indicated. Make sure you understand the differences in the terms: diverticulosis, diverticulitis and diverticular disease.

Question 53

Management:
A 17-year-old woman with a FH of headaches has now herself developed headaches which are throbbing in character and preceded by flashing lights. She wonders what her GP can do for her.

Answer 53

Aspirin

Migraine is a chronic condition, with genetic determinants, which usually presents in early to mid life. The typical migraine aura this patient describes (which can be visual, sensory or speech symptoms) which can occur during or before the headache, is pathognomic, but is not seen in the majority of patients. The aura can be positive phenomena (for example this patient seeing flashing lights) or negative phenomena (for example visual loss). Nausea, photophobia and disability (the headache gets in the way with the patient’s ability to function) accompanying a headache also suggest a migraine diagnosis. The headache of a migraine tends to be prolonged if untreated, and tends to be unilateral and pounding (but does not have to be). Tests aim to rule out other differentials, although if the history is compatible and neurological examination is unremarkable, further testing is not needed.

Treatment of this chronic condition aims at treating acute attacks to restore function. Triptans can be used in specialist care for severe symptoms. These are 5HT1 agonists. Effective initial treatment in a primary care setting can involve NSAIDs, which are available OTC and include aspirin, as well as indometacin and naproxen. Paracetamol is less effective than NSAIDs but is still better than placebo – it is first line in those who are pregnant. Treatment should be taken as soon as a patient realises they are having an attack and may need to be repeated after the attack. A few patients who have frequent, severe or disabling headaches may require daily prophylaxis such as anticonvulsants, TCAs and beta blockers.

Question 54

Diagnosis:
A 65-year-old man presents with a large painless bladder and overflow incontinence at night and a raised creatinine level.

Answer 54

Hydronephrosis

This patient has BPH which has caused hydronephrosis. This is an example of bilateral obstructive uropathy. Acute presentations are often painful whereas chronic presentations are more insidious in onset. Blockage of urinary flow by the enlarged prostate has led to urinary retention and overflow incontinence. Initial treatment aims to relieve the pressure on the kidneys. This involves catheterisation as the first line treatment. The patient should be started on alpha blockers at the time of catheterisation.

Question 55

Monitoring:

Pravastatin

Answer 55

Liver function tests

Pravastatin is a statin. Other statins include the mighty atorvastatin, simvastatin and rosuvastatin. They inhibit HMG-CoA reductase, which is an enzyme involved in the cholesterol synthesis pathway. They hence lower LDL cholesterol levels very effectively to reduce the cardiovascular disease. Statins can cause altered LFTs and rarely even hepatitis and jaundice. There have also been rare case reports of liver failure. NICE have a guideline (which we must listen to…) which state that liver enzymes should be measured before treatment and repeated within 3 months and at 12 months of starting treatment (unless there are obvious signs and symptoms of hepatotoxicity).

Question 56

Monitoring:

Cyclophosphamide

Answer 56

White cell count

This drug is used mainly with other drugs for treating malignancies including leukaemias, lymphomas and solid tumours. The rare and serious complication is haemorrhagic cystitis as a result of the urinary metabolite acrolein and mesna can be given as prophylaxis. It is an alkylating agent which damages DNA and interferes with cell replication. The only feasible option on this list is WCC where we have to assume this drug is being used for a leukaemia or lymphoma and we want to measure whether it is working.

Question 57

Diagnosis:
A 22-year-old man has developed multiple hard swellings on the left side of the neck. He has had night sweats and anorexia for two months.

Answer 57

Hodgkin’s disease

This is a case of lymphoma. Reed-Sternberg cells are binucleate cells characteristically seen in Hodgkin’s lymphoma. Hodgkin’s is localised to a single group of nodes (normally the cervical and/or supraclavicular) and extranodal involvement is rare. Mediastinal involvement is common. Spread is contiguous and B symptoms may be present such as a low grade fever, weight loss and night sweats. Pruritis may be found in approximately 10% of cases but has no prognostic significance. 50% of cases is associated with EBV infection and distribution is bimodal with peaks in young and old. There is classically pain in lymph nodes on alcohol consumption.

Question 58

Diagnosis:
A 20-year-old medical student is concerned about recent weight gain, lethargy and constipation. You notice bradycardia and a goitre. Her ankle reflexes are sluggish. Her periods have stopped.

Answer 58

Myxoedema

This medical student has hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Symptoms include those mentioned (weight gain, lethargy, sluggish reflexes, bradycardia and constipation) as well as depression, fatigue, constipation, cold intolerance, menstrual problems in females, dry skin and muscle cramps. Diagnosis is based on measurement of TSH and thyroid hormones. Treatment is by replacement of T4 with or without T3 in combination. If the patient has normal T3 and T4 but mildly elevated TSH, this is described as subclinical hypothyroidism.

Question 59

Management:

A 55-year-old woman with a 6-week history of intermittent angina is found to have a serum cholesterol of 7.9 mmol/l.

Answer 59

Perform exercise ECG

This patient has presented with stable angina. Resting ECG is often normal however during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.

Question 60

Management:
A 30-year-old teacher presents to her GP with a cough and shortness of breath, worsening over 48 hours following a ‘flu-like illness. On examination, she has a temperature of 39ºC. There is little to find on chest examination, but the chest x-ray shows bilateral shadowing.

Answer 60

Oral clarithromycin

This is a CAP which is confirmed by CXR shadowing, which would show airspace shadowing with air bronchograms. The history is also consistent with respiratory symptoms and pyrexia. The most sensitive test for CAP is a CXR. The treatment is initially empirical with antibiotics and management would be guided by this patient’s CURB-65 score. A macrolide is the first choice in adults with no contra-indications without a recent cours eof antibiotics or risk of drug resistance, but always check local prescribing policies. Azithromycin, clarithromycin or erythromycin are all valid choices here.

Question 61

Management:
A 40-year-old male smoker with COPD is in hospital with a 2 week cough productive of green sputum with SOB for 24 hours. Temperature is 39.3ºC, RR 35/min, and HR 120/min. There is dullness to percussion and reduced breath sounds at the left base. He is given nebulised salbutamol and systemic corticosteroids.

Answer 61

IV cefuroxime

This is an acute infective exacerbation of COPD and the patient has already received nebulised salbutamol and corticosteroids. The next important thing to do is to give IV antibiotics. Inpatient therapy for severe infections can be with IV ceftriaxone with azithromycin. High risk patients should receive piperacillin and tazobactam, or meropenem, to cover for pseudomonas.

Question 62

Management:
A 60-year-old man has been diagnosed as having bronchial carcinoma with secondaries. He is distressed by a chronic cough.

Answer 62

Opiate

Opiates are commonly prescribed for analgesia and can also be used as an anti-tussive in this case (suppresses ACh and NK release needed for cough activation and inteferes with serotonin receptors in the DRN). They are also abused for their euphoric effects mediated by their action on dopamine release at the nucleus accumbens. They have a host of side effects: GI effects (receptors present on the myenteric and submucosal plexus) of decreased gastric motility, emptying and increased gut water reabsorption… in short, constipation; Respiratory depression (desensitises central chemoreceptors to lessen the response to PaCO2); N&V by stimulating the CTZ; Pupillary constriction via the Edinger-Westphal nucleus; And causes symptoms like pruritis, urticaria, hypotension through histamine release via a direct effect on mast cells.

Question 63

Ix:
A 57-year-old Asian male smoker was treated successfully for pulmonary TB last year. He has had nausea for a month and over the last week has vomited after every solid meal. He has lost 5 kg in weight in that period and has some abdominal discomfort. He feels food getting stuck behind the bottom of his sternum. Examination is unremarkable.

Answer 63

Gastroscopy

Weight loss is one of the most common presenting symptoms in patients with gastric cancer. Epigastric pain is present in about 80% and may resemble that of a gastric ulcer. Although commonly mentioned in EMQs, lymphadenopathy is an uncommon presentation. More proximal tumours can also present with dysphagia. Strong risk factors include pernicious anaemia, Helicobacter pylori and the consumption of N-nitroso compounds found in cured meats. The peak incidence occurs between 50-70 and men are twice as likely to have gastric cancer. Most are adenocarcinomas. The first test to order for suspected gastric malignancy is an urgent upper GI endoscopy with biopsy of the lesion. The mainstay of treatment is surgical resection unless there is evidence of metastatic disease.

Question 64

Ix:
An 83-year-old lady complains of feeling tired and breathless on exertion since a brief episode six weeks ago which another doctor diagnosed as gastroenteritis. However, the diarrhoea has not improved. A blood test you did last week shows a microcytic anaemia.

Answer 64

Colonoscopy

This lady needs to be investigated for bowel cancer. There are symptoms and confirmation of IDA which could be due here to GI bleeding. There is also diarrhoea which has not improved and is now chronically a problem. Along with advanced age, this raises the suspicion of malignancy and a colonoscopy needs to be done.

Question 65

Ix:
A 32-year-old male nurse from Zimbabwe came into the UK as part of an NHS recruitment campaign. He presents with SOB, weight loss, general debility, cervical lymphadenopathy and purple tender lesions on his shin of 6 weeks duration.

Answer 65

Chest x-ray

Sarcoidosis is a chronic multisystem disease with an unknown aetiology with the lungs most commonly affected (giving SOB in this case). The purple lesions are erythema nodosum and are tender erythematous nodules. Lupus pernio is another typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. Additionally, serum calcium and ACE levels may be raised. A transbronchial biopsy is essential for diagnosis in most cases and shows the presence of non-caseating granulomas. Black people have a higher lifetime risk of sarcoidosis, as do those of Scandinavian origin. The mainstay of treatment for severe disease involves systemic corticosteroids.

Question 66

Ix:
A 78-year-old man presents with low back pain that doesn’t improve with rest. He has non-specific intermittent abdominal pain and night sweats. Investigations reveal a haemoglobin of 9.6 g/dL, a corrected calcium of 2.97 mmol/L, and an ESR > 100 mm/hr.

Answer 66

Bone marrow aspirate

This patient has multiple myeloma. This is characteristed by clonal proliferation of plasma cells in BM and commonly presents with bony pain and symptoms of anaemia (which this patient’s Hb demonstrates). The elevated ESR is also suggestive and hypercalcaemia is present in 30%. The diagnostic test is serum or urine electrophoresis looking for a paraprotein spike of IgG or IgA and light chain urinary excretion (Bence Jones proteins). Bone marrow examination and skeletal survey will also need to be conducted. Bone marrow aspirate in this case and biopsy will show plasma cell infiltration in the bone marrow, and can help to differentiate multiple myeloma from MGUS and solitary plasmacytoma. Bone changes include osteopaenia, osteolytic lesions and fractures.