passmedicine questions
how much adrenaline would you give in a child under 6 months
150 micrograms 6-12yrs 300 micrograms adult 500 (10.5ml 1 in 1,000) hydrocortisone- 200mg chlorphenamine 10mg
A 6-year-old boy is brought to surgery by his mother. For the past 2 months he has been complaining of pain in his shins and ankles at night-time. His symptoms are bilateral he is otherwise well. There is no family history of note. Clinical examination is unremarkable. What is the most likely diagnosis?
A common presentation in General Practice is a child complaining of pain in the legs with no obvious cause. Such presentations, in the absence of any worrying features, are often attributed to 'growing pains'
A 70 year old retired miner is noted to have a palpable liver during a routine examination. He is a smoker of 60 pack-years and has been using an inhaler for the last seven years. On examination he has hyperinflated lung fields to percussion and minimal wheeze. His chest x-ray reveals hyperinflated lung fields with enlarged great vessels and a small vertical heart shadow.
Alpha 1-antitrypsin deficiency- both emphysema and liver failure
path physiology of alpha 1 antriypsin
Alpha-1 antitrypsin (A1AT) is produced in the liver, and one of its functions is to protect the lungs from neutrophil elastase, an enzyme that can disrupt connective tissue. many of these patients will develop emphysema due to lack of elastase and also develop liver cirrhosis as the alpha 1 antitrypsin builds up and becomes toxic
A 35 year-old lady attends the GP practice complaining of heavy painless periods which are interrupting with her lifestyle and causing her distress at work. She is currently in the process of trying for a family. The most suitable option is
As her periods are painless, there is no need for her to take mefenamic acid, an NSAID, which is also not recommended in pregnancy. The most appropriate answer is therefore tranexamic acid, a plasminogen activator inhibitor that acts as an anti-fibrinolytic to prevent heavy menstrual bleeding.
what is glucose 6 phosphate dehydrogenase deficiency
G6PDS- Glucose-6-phosphate dehydrogenase deficiency is an X linked disorder affecting red cell enzymes. It results in a reduced ability of the red cells to respond to oxidative stress. Therefore, red cells have a shorter life span and are more susceptible to haemolysis, particularly in response to drugs (e.g. nitrofurantoin), infection, acidosis and certain dietary agents (e.g. fava beans). Features neonatal jaundice is often seen intravascular haemolysis gallstones are common splenomegaly may be present Heinz bodies on blood films
giardiasis symptoms
Giardiasis is an parasitic infection and the child normally has watery stools, nausea and fever.
Henry is a 29 week premature baby who was born 2 weeks ago. Over the past week it has been noted that he has had bloody stool, abdominal distension and has not been feeding well. Physical examination reveals an increased abdominal girth with reduced bowel sounds. Abdominal X-ray shows dilated asymmetrical bowel loops and bowel wall oedema. What is the likely diagnosis?
Necrotising enterocolitis is one of the leading causes of death among premature infants. Initial symptoms can include feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis
what is osgood schlatter disease?
Osgood-Schlatter disease may be diagnosed on the basis of clinical features alone. This age group (adolescent) is the most likely age to suffer from this condition and is localized to the tibial tuberosity. Typically, pain is: Unilateral (but may be bilateral in up to 30% of people). Gradual in onset and initially mild and intermittent, but may progress to become severe and continuous. Relieved by rest and made worse by kneeling and activity, such as running or jumping.
presentation of ovarian cancer
Ovarian cancer usually presents with minimal symptoms and rarely PMB - more frequently patients will complain of bloating, abdominal pain, weight loss, urinary incontinence.
what should you think when you hear painless haematuria
Painless haematuria should ring alarm bells for bladder cancer
A 24-year-old lady from Western India presents with symptoms of lethargy and dizziness, worse on turning her head. On examination her systolic blood pressure is 176/128. Her pulses are impalpable at all peripheral sites. Auscultation of her chest reveals a systolic heart murmur.
Takayasu's arteritis most commonly affects young Asian females. Pulseless peripheries are a classical finding. The CNS symptoms may be variable.
A 54-year-old female presents to the endocrinology clinic following referral from her GP. His referral letter gives a background of treatment resistant hypertension and polyuria, with additional symptoms of tingling in the fingertips and increasing fatigue. It is reported that routine bloods were deranged, but you are unable to find them on the system. An MRI scan performed as an outpatient shows a small suspected adenoma in the right adrenal gland and nil else of note. Which arterial blood gas would be consistent with the underlying condition?
resitant hypertension and hypokalemia - muscle weakness think conns abg would show alkalosis
child presenting complaint is nocturnal enuresis, has gone through all non pharmacological treatment like reducing fluid intake,rewarding behaviour diet and other obvious triggers like constipation, diabetes mellitus or uti have been avoided name one other non pharmacological and pharmociligical treatment that the patient can try
can have reward system can use an enurises alarm drug wise- if above 8 years old can prescribe desmopressin
what is tuberous sclerosis
case- A 19-year-old man is admitted following a generalised seizure. No past history is available as the man is currently in a postictal state. On examination it is noted that he has three patches of hypopigmented skin and fibromata under two of his finger nails. What is the most likely diagnosis? Given the areas of hypopigmentation and subungual fibromas the most likely diagnosis is tuberous sclerosis and epilepsy (can also get infantile spasms
You are working on the neonatal unit and examine a new-born baby. On examination you note a small left sided haematoma over the parietal bone. It does not extend beyond the margins of the parietal bone and is soft to touch. The baby is otherwise well. The baby was born by spontaneous vaginal delivery at term. There were no problems prenatally or during labour. most likely diagnosis
cephalohaematoma- don't cross the suture lines cranial abrasions occur in c section or instrumental delivery Chignon's are birth traumas that occur after use of a ventouse device during deliver
A 14 year old girl presents to her General Practitioner accompanied by her mother. She describes she has not progressed as far in puberty as her friends. She used to be the tallest in her class in infant school, but is now shorter than most of her peers. On examination she has stage II breast development and stage III pubic hair. Her blood pressure is 135/110mmHg in her right arm
chronic kidney disease in children can stop growth spurt, and prevent the use of growth hormone
patient copmes in with new onset astham, bilateral wheeze. facial pain and nasal polyps are found A chest x-ray demonstrated pulmonary infiltrates. what is the most likely diagnosis and investigations
chrug straus syndrome and investigations check pANCA levels treatement with high dose of corticoid steroids and if not controlled then add immunosuppressants
A 59-year-old man with no significant past medical history is admitted to hospital following an ischaemic stroke. He presented outside of the thrombolysis window and is treated with aspirin for the first few days. His blood pressure is 130/80 mmHg, fasting glucose is 5.6 mmol/l and fasting cholesterol is 3.9 mmol/l. He makes a good recovery and has regained nearly all of his previous functions upon discharge. Following recent NICE guidelines, which of the following medications should he be taking upon discharge (i.e. after 14 days)?
clopidogrel and statin
A 28 year old woman presents with abdominal pain. She was treated for a peri-anal disorder two years previously. Investigations show a macrocytosis and raised c-reactive protein.
crohns perianal disease- Perineal inspection may show fissures or fistulae for uc eri anal disease is usually absent.
A six hour old baby girl born at term is recognised by the midwife to be grunting. She is of Indian origin. She was born by normal vaginal delivery following the rupture of her mother's membranes 36 hours previously. On examination she has a respiratory rate of 70/min, flaring of the alae nasae and marked intercostal recession. Oxygen saturation measured 80% in air name the pathogen
group b streptococcus- most common cause of infection septicaemia meningitis in children
A 60 year old woman presents with a retrosternal chest pain, associated with regurgitation of gastric acid into the mouth. A chest x-ray reveals an air fluid level overlying the cardiac shadow. Her body mass index is 34
hiatus hernia- air fluid level is characteristic
treatment for fibroids and investigation
investigation transvaginal ultrasound Management symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line other options include tranexamic acid, combined oral contraceptive pill etc GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy uterine artery embolization
You are reviewing test results. The midstream specimen of urine (MSU) from a 24-year-old woman who is 11 weeks pregnant shows a urinary tract infection. On discussing the result with the patient she does describe some dysuria and 'smelly urine'. What is the most appropriate management?
nitrofurantoin for 7 days trimethoprim is teratogenic
A 6-year-old boy is noted to have pectus excavatum and pulmonary stenosis during a cardiorespiratory exam. What is the most likely diagnosis?
noonans sydnrome also get webbed neck and short stature
A 70 year old man is admitted acutely with three hours of severe lower back and abdominal pain. He has no history of vomiting or diarrhoea. On examination, he is tender in the mid abdomen with a pulsatile mass which is palpable centrally. He has poor peripheral pulses in both legs. imaging
normally ultrasound but if aneurysm is approaching 5cm then ct contrast scan
risk factors for developmental dysplasia of the hip
oligohydramnios breech presentation birth weight over 5kg positive family history more common in the left hip but 20 percent are bilateral foot deformities treatment: most unstable hips strengthen by 3-6 weeks otherwise a pavlik harness is worn which flexes and abducts the knees n older children may require surgery
An 88 year old man presents with a sensation of burning in his mouth. He has a history of chronic obstructive pulmonary disease, and has had several courses of antibiotics recently. He has lost weight and eats poorly. His body mass index is 18.
oral candiasis associated with broad spectrum antibiotic usage
A 25 year old woman presents to the Accident and Emergency Department with severe vaginal bleeding at 35 weeks gestation in her first pregnancy. Her blood pressure is 140/100mmHg and her heart rate is 100/min. There is 2+ protein on urine dipstick analysis.
placenta abruption beware of pre eclampsa dic or anuria
what is plagiocephaly
plagiocephaly is more common since there have been campaigns to encourage babies to sleep on their back to reduce the risk of sudden infant death syndrome (SIDS). Plagiocephaly is a skull deformity producing unilateral occipital flattening, which pushes the ipsilateral forehead ear forwards producing a 'parrallelogram' appearance. The vast majority improve by age 3-5 due to the adoption of a more upright posture. Helmets are not usually recommended as there was no significant difference between groups in a randomised controlled trial. Turning the cot around may help the child look the other way and take the pressure off the one side.
8. A 17 year old girl comes to see you because she has not started her periods. She has always been shorter than her friends, and is below the third centile of height for her age. The rest of her family are of normal height. On examination she has no breast development and no pubic hair development.
puberty delay with short stature think turners syndrome can also be noonans or praderwill syndrome
A 23 year old man presents complaining of an 18 month history of intermittent low back discomfort. This has been associated with numbness and tingling in the left leg. Pain is relieved by resting and he reports no nocturnal symptoms. He has noticed mild urinary incontinence. Examination reveals no abnormal neurology in the lower limbs and no other significant clinical findings. investigation of choice
query cauda equina syndrome mri scan
if relapse after thermostatic drug is prescribed, what is the next line permanent treatment
radioiodine therapy
A young man presents two weeks after returning from holiday in Spain, with a painful swollen knee which he cannot fully bend. On examination the knee is swollen with a positive patellar tap, and is warm to the touch. He describes an episode of diarrhoea whilst on holiday for which he was treated with antibiotics.
reactive arthritis post sti post dysentry
A 1-year-old girl is investigated for recurrent urinary tract infections. A micturating cystourethrogram is ordered: shows bilateral dilatation of the ureters, renal pelvis and calyces
vesicoureteric reflux
A 25 year old woman is referred from the optician following an episode of blurred vision 18 months previously and a recent episode of double vision in the last week. In the last 3 months she has also found that she can suddenly experience the feeling of needing to go to pass urine and has to rush to get to the toilet in order to avoid wetting herself.
multiple sclerosis
treatment for fibroids that are causing sub fertility and for a woman that is trying to have kids
myomectomy
treatment once an individual with mrsa is found
nasal mupirocin and chlorhixadine
An 8-year-old boy presents to his GP complaining of fatigue and excess sleep. An initial set of results indicated that reticulocytes and the bilirubin level were raised. A set of further blood tests reveal, microcytic anaemia
B thalassemia extrahemopoeisis- splenomegaly causing abdominal discomfort and ruq pain due to gallstones causing a raised bilirubin
Ms. Andrews a 24-year-old sales promoter was diagnosed with left tubal ectopic pregnancy 3 weeks ago. She was started on medical treatment with methotrexate and her progress was then closely monitored. However, her hCG titres failed to respond adequately. Surgical treatment was indicated and considered. She has no significant medical history and is medically fit. Which of the following surgery is mostly likely to be carried out by the surgeon?
Based on the NICE guidelines, salpingectomy is offered to women who has a tubal ectopic unless they have other risk factors for infertility eg. Contra lateral tube damage. Otherwise, salpingotomy is offered as an alternative. answer: salpingectomy
A 25-year-old junior doctor has a chest x-ray performed as part of a routine insurance medical examination. The x-ray shows evidence of rib notching. Auscultation of his chest reveals a systolic murmur which is loudest at the posterior aspect of the fourth intercostal space.
Coarctation of the aorta may occur due to the remnant of the ductus arteriosus acting as a fibrous constrictive band of the aorta. Weak arm pulses may be seen, radiofemoral delay is the classical physical finding. Collateral flow through the intercostal vessels may produce notching of the ribs, if the disease is long standing.
management of menorrhagie
Does not require contraception either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period if no improvement then try other drug whilst awaiting referral Requires contraception, options include intrauterine system (Mirena) should be considered first-line combined oral contraceptive pill long-acting progestogens
treatment of secondary hyperparathryoidism
In individuals with chronic kidney disease, this being the most common cause of secondary hyperparathyroidism, treatment consists of dietary restriction of phosphorous, supplemented with active vitamin D and phosphate binders. Most patients will improve following renal transplantation. phosphorous food meats, poultry, fish, nuts, beans and dairy products
give an example of gnrh agonist used for fibroids
Leuprolide
x ray findings of emphysema
Low set diaphragm Flat diaphragm best determined by lateral chest Hyper lucent lung fields- due to lack elastic coil Increased AP diameter Increased retrosternal air Vertical heart shadow [] [] [] heart looks like that
A 14 year old girl presents for follow up. She has a cough productive of green sputum. She has cystic fibrosis and is of white British origin. She is otherwise well. Despite a course of amoxicillin and flucloxacillin the cough and sputum have not resolved. She has lost 1kg in weight since her last clinic visit. On examination, there are no signs of respiratory distress. There are coarse crackles at her right base. Correct Answer I)
Pseudomonas aeruginosa the four common organises that colonise in cystic fibrosis Staphylococcus aureus Pseudomonas aeruginosa Burkholderia cepacia* Aspergillus
A 48-year-old man notices that he is becoming increasingly dizzy when he plays squash, in addition he has also developed cramping pain in his left arm. One day he is inflating his car tyre with a hand held pump, he collapses and is brought to hospital.
Subclavian steal syndrome is associated with a stenosis or occlusion of the subclavian artery, proximal to the origin of the vertebral artery. As a result the increased metabolic needs of the arm then cause retrograde flow and symptoms of CNS vascular insufficiency.
what blood results would coincide with dka
The blood results are concurrent with a diagnosis of DKA. Bloods will often show a hyponatraemia, low bicarbonate and a hypokalaemia in severe cases. The low bicarbonate in this question gives the indication that there is an acidosis in this patient
if patient with large pleural effusion but stable, what would be the management
The first step in the management of this patient is pleural aspiration, preferably under ultrasound guidance. This will help guide further management and determine the aetiology of the effusion. There is no need for immediate chest drain insertion as she is stable.
what diet can be used to help with epilepsy
The ketogenic diet is a high fat, low carbohydrate, controlled protein diet. It is an established treatment for children with epilepsy that is hard to control and is generally unresponsive to antiepileptic medications. Following the diet requires specialist input from an epilepsy specialist and a dietician.
A 4-year-old boy was discharged from the hospital six weeks ago after an episode of viral gastroenteritis. He now has 4-5 loose stools each day which has been present for the past four weeks. What is the most likely diagnosis?
Transient lactose intolerance is a common complication of viral gastroenteritis. Removal of lactose from the diet for a few months followed by a gradual reintroduction usually resolves the problem.
A 4-year-old girl is reviewed by her GP due to poor control of asthma. She currently takes a regular steroid inhaler (Clenil - 50 mcg two puffs bd) and a salbutamol inhaler as required. What is the next step in management?
Trial of a leukotriene receptor antagonist as she is below 5 years if it was above 5 year- long acting beta agonist
A 12-year-old boy presents to clinic complaining of having to urinate more frequently. Upon assessment you decide to investigate for type 1 diabetes mellitus. Which of the following would most likely support this diagnosis? Weight gain Family history of type 2 diabetes mellitus Excessive tiredness Black or Asian family origin Evidence of acanthosis nigricans
Weight loss is associated with type 1 diabetes mellitus. Genetic factors such as family history and racial origin are more associated with type 2 diabetes mellitus. Acanthosis nigricans is a sign of insulin resistance, also associated with type 2 diabetes mellitus answer is excessive tiredness
A 56-year-old man with metastatic prostate cancer comes for review. He is known to have spinal metastases but until now has not had any significant problems with pain control. Unfortunately, he is now getting regular back pain despite taking paracetamol 1g qds. The pain is stopping him sleep at times. Neurological examination is unremarkable. What is the most appropriate next step?
Whilst there is a role for oral bisphosphonates in treating such pain the effects may take several weeks to materialise and the number needed to treat is higher than that of strong opioids. Referral to a clinical oncologist should be considered for all patients with such pain as radiotherapy is an effective treatment. so answer is strong opiod
contraindications of thrombolysis
absolute contraindications Any previous history of hemorrhagic stroke, ischemic stroke within 3 months. History of stroke, dementia, or central nervous system damage within 1 year Head trauma within 3 weeks or brain surgery within 6 months Known intracranial neoplasm Suspected aortic dissection Internal bleeding within 6 weeks Active bleeding or known bleeding disorder Traumatic cardiopulmonary resuscitation within 3 weeks relative acute pancreatitis oral anticoag peptic ulceration
A 51 year old man presents with fever, abdominal pain and diarrhoea. He also gives a six month history of joint pains. An abdominal CT scan is normal. A small bowel biopsy shows periodic acid-Schiff positive rods within the macrophages
acid shift positive rods- whipples disease
A married woman, 31 years of age, is admitted with vomiting, abdominal pain and confusion. She has recently started a combined oral contraceptive pill after entering into a new relationship. Her mother had similar symptoms in her mid 30's. diagnosis and investigation
acute intermittent porphyria- autosomal dominant defect in prophobilinogen deaminase an enzyme involved in the biosynthesis of harm. characteristically presents with abdominal and neuropsychiatric 20-40 yrs cocp or other drugs like benzos can exacerbate symptoms urine porphyrin estimation
A 63 year old woman with rheumatoid arthritis since the age of 19 presents with general lethargy. On examination she has a palpable liver and signs of symmetrical deforming arthritis consistent with rheumatoid disease. Her liver function tests are normal
amyloidosis- rheumatoid arthirits in developing countries is the main instigator for amyloidsis
A 1-year-old child is brought into your surgery for a routine examination. His parents are worried that he is too small for his age. On further questioning his parents explain he is difficult to feed, and eats a milk and soft food based diet. He is otherwise asymptomatic. On general examination he looks healthy but is on the 3rd centile for weight. Cardiac examination reveals a systolic murmur in the pulmonary area and a fixed splitting to the second heart sound. Pulses are all palpable and within normal range What is the most likely diagnosis?
atrial septal defect On examination you would typically hear a ejection systolic murmur and fixed splitting of the second heart sound
A 60-year-old man who is known to have lung cancer comes for review. For the past three weeks he has lost his appetite, has been feeling sick and generally feels tired. On examination he appears to be mildly dehydrated. You order some blood tests: high calcium which one would cause it Amlodipine Simvastatin Bendroflumethiazide Aspirin Lisinopril
bendrofluemthiazide- high calcium
A 66 year old woman presents to her General Practitioner after a fall. She describes that the episode was preceded by the onset of dizziness while hanging out washing. She fell and had difficulty getting back up. She vomited twice but was not incontinent and did not bite her tongue. Her symptoms have improved gradually, but have recurred abruptly over the few days since the first episode. On examination she is well, but certain head movements provoke her symptoms and induce nystagmus.
benign position vertigo
A 23 year old woman attends a fertility clinic with her partner. She complains of oligomenorrhoea and galactorrhea and has failed to get pregnant after 18 months of regular unprotected intercourse. Blood tests reveal a serum prolactin level of 6000 mIU/l (normal <500 mIU/l). A pituitary MRI is arranged which shows a microprolactinoma. Which of the following is the best initial treatment?
bromocriptine This patient has a prolactinoma. In the majority of cases, symptomatic patients are treated medically with dopamine agonists (e.g. bromocriptine) which inhibit the release of prolactin from the pituitary gland. Surgery is performed for patients who cannot tolerate or fail to respond to medical therapy. A trans-sphenoidal approach is generally preferred unless there is significant extra-pituitary extension
what is the stepwise management of epilepsy or seizure
buccal midazolam iv lorazapam iv phenytoin Rapid sequence induction of anaesthesia using thiopental sodium
A 16 year old girl presents to her General Practitioner accompanied by her mother. She describes that she has not yet commenced her periods. She has always been fit, and was a regional cross-country champion, but now feels tired all the time and has recently had to stop running. She is below the third centile weight for her age, and on the 25th centile height for her age. She has stage II breast development, and is just beginning to develop pubic and axillary hair. She has several painful mouth ulcers, and complains of abdominal pain after eating. Her haemoglobin is 10.1g/dL (normal range 11.5-16.5g/dL), the mean corpuscular volume is 75fL (80-96fL), and her C-reactive protein is 22mg/L (<10mg/L).
crohns disease ulcers along the go tract
A 14 year old girl presents to her General Practitioner accompanied by her mother, concerned that, unlike her friends, she has not started her periods and has not developed breasts. She has always had problems with her chest, and is on long-term treatment for asthma. She was admitted to hospital with pneumonia several years ago. She is on the third centile weight for her age, has stage II breast development and some pubic and axillary hair. She also has mild clubbing of her fingers. Her faecal elastase level is below the limit of detection.
cystic fibrosis-causes delayed puberty elastase is a pancreatic enzyme, which helps to break down connective tissue
A 45-year-old alcoholic patient starts to fit in the waiting room. You place him in the recovery position and apply oxygen. After 5 minutes he is still fitting. What is the most appropriate medication to administer?
diazepam 10mg
symptoms of oestrogen deficiency
dryness and urinary frequency
what is achondroplasia
dwarfism
A 3-year-old girl presents with a 3 day history of fever and bloody diarrhoea. Over the past 24 hours she has had 5 episodes of loose bloody stools. On examination she has a temperature of 39.6ºC, a heart rate of 175 bpm and her abdomen is soft with generalised tenderness. It is also noted that she has a reduced urinary output. Blood tests show a haemolytic anaemia and raised urea. gram negative bacteria What is the most likely diagnosis?
e.coli gastroenteritis rasied urea (renal failure) and haemolytic anaemia- indicate haemolytic uraemic syndrome the only thing missing is thrombocytopenia treatment is supportive, antibiotics are contraindicated
A 35 year old patient presents with a four day history of vaginal bleeding. Ten days ago she had a forceps delivery for delayed labour at 39 weeks in her second pregnancy. On examination her pulse and blood pressure are normal. The uterus is enlarged and tender
endometriasis Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery. Causes: endometritis: most common cause
A 50 year old man presents to his General Practitioner with a three month history of an intensely itchy eruption which began on his legs but which has now spread to the arms. He has had no previous skin disease and no one in the family has had skin problems. His General Practitioner prescribes a moderate potency topical steroid and refers him to the dermatology department. At his appointment with the dermatologist two months later, there has been no improvement. On examination he has numerous discrete circular scaly excoriated patches with evidence of crusting. These are predominantly on his limbs
excoriations - discoid ezcema
A 56 year old woman presents with recurrent infections. She has a long history of rheumatoid arthritis. On examination there is 5cm splenomegaly. Standard blood tests reveal white blood cell count 4.5 x 109/L (normal range 4-11 x 109/L) and haemoglobin 9.4 g/L (11.5-16.5g/dL).
felty's syndrome
A 75 year old woman presents with an exquisitely painful swollen knee which is warm to the touch. She is finding it difficult to walk to the toilet. This is particularly problematic for her as she suffers from urinary frequency which she attributes to her furosemide tablets
furosemide- big risk factor for gout
An 8-year-old boy presents with increasing jaundice over the past week. He was recently treated with nitrofurantoin for a simple urinary tract infection. On examination he is obviously jaundiced, and he is looking pale and breathless. Investigation results are as follows: Hb 58 g/l Platelets 250 * 109/l WBC 6.5 * 109/l A blood films demonstrates red cell fragments and Heinz bodies what is the diagnosis?
glucose 6 phosphate dehydrogenase deficiency
A 60 year old man has a long history of gastro-oesophageal reflux symptoms, with pain on swallowing. He underwent an upper gastro-intestinal endoscopy 2 months ago, with no malignancy seen. He contiues to have difficulty swallowing. His body mass index is 24.
gord and endoscopy are both risk factors for oesophageal stricture
what is neurofibromatosis
its a benign tumour that grows along the nerves autososmal dominant two types type 1 most common skin symptoms: freckles in unusal places axilla groin cafe au spots (indicates neurocutaneous syndromes neurofibromas which are lumps under the skin scoliosis leanring difficulties: mild cognitive impairment- stuggle with radin or wiritng can aalso have attention deficit disorder or be part of the autism spectrum the eyes: can get optic pathway glioma (OPG)- CASUE BLURRING THE CHILDS VISION- may bump into things can also get brown spot on the iris- Lisch nodules high blood pressure- phaemocytochropma physical development- may have scoliosis may have larger heads may be generally small can also develop psuedoarthiritis- pathological fractures
explain the pathophysiology of renal osteodystrophy
kidneys not being able to convert enough vitamin D to its active form and they are also not able to adequately excrete phosphate. Due to this insoluble calcium phosphate forms, removing calcium from the circulation, which results in hypocalcaemia. The parathyroid glands detect this and secrete parathyroid hormone to try and raise serum calcium levels. This is achieved through several mechanisms, including increasing the osteoclastic activity of bone, resulting in renal osteodystrophy.
A 40 year old man presents at an infertility clinic. He and his wife have been unable to have children, although his wife has a child from her first marriage. On examination, he is 1.9m (6' 4") tall, with gynaecomastia and small testes.
klinefelters sydnrome
A 78-year-old man is admitted to the stroke ward. You are asked to examine him. He denies any headache. You find he has normal motor function but has completely lost sensation on the right hand side of his body. There is no hemianopia or dysphasia. What type of stroke is this?
lacunar stroke
A 25 year old man presents to his General Practitioner with headache, fever and malaise. He is a keen canoeist. On examination the patient has hepatosplenomegaly and lymphadenopathy. There appears to be suffusion of the conjunctiva. Full blood count is normal.
leptospirosis farmers sewage workers anything in contact with rats urine risk of hepatorenal failure symtpoms fever flu-like symptoms renal failure (seen in 50% of patients) jaundice subconjunctival haemorrhage headache, may herald the onset of meningitis
A 55 year old woman presents to her General Practitioner with a four week history of an itchy eruption. The use of a moisturiser has not had any effect. She had a similar rash 15 years ago and it lasted for 12 months. On examination there are numerous flat topped purplish papules located over her forearms and flexor aspects of the wrists. She has several relatively painless ulcers on buccal mucosa.
lichen planus itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms rash often polygonal in shape, 'white-lace' pattern on the surface (Wickham's striae) Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma) oral involvement in around 50% of patients nails: thinning of nail plate, longitudinal ridging
A 55 year old man is investigated in a medical ward for unexplained chest pain. Three days after admission he becomes agitated. On examination he has a tremor of the outstretched hands and believes that the animals in the pattern of his bedspread are coming towards him at night.
mcv increases with excessive alcohol intake can also look at liver function tests
childhood infections The prodrome is characterised by fever, irritability and conjunctivitis? May cause vesicles in the mouth and on the palms May cause a crop of white spots on the inside of the mouth
measles coxsackie a16-hand foot mouth disease measles-koplik spots
A 4-year-old boy is admitted with abdominal pain and painless haematuria. On examination, there is a mass on palpation of the left flank. What is the most likely diagnosis?
most common renal tumour in children is WILMS tumour, one of the most common childhood malignancies Management nephrectomy chemotherapy radiotherapy if advanced disease prognosis: good, 80% cure rate
A 10-month-old boy is brought to surgery. Around 4 days ago he developed a fever after being irritable the previous day. The fever settled after around 3 days but following this he developed a rash, which prompted his mother to bring him to surgery. He is taking around 75% of his normal feeds, is producing wet nappies and has had two episodes of loose stools. On examination he is alert, temperature is 37.0ºC, chest is clear, ears/throat unremarkable. There are a number of blanching, rose pink macules present on his trunk. What is the most likely diagnosis?
roseola infactum fever- followed by rash maculopapular blanching The rash typically starts abruptly after the temperature subsides, and usually starts on the trunk before spreading to the limbs. It is a maculopapular rash and it not itchy.
An 80 year old woman with dementia is visited in her nursing home by her General Practitioner after staff are concerned that she is uncontrollably scratching herself. On examination she has numerous excoriated papules on her upper limbs and trunk. Her General Practitioner has previously prescribed oral antibiotics and a topical steroid, but this only produced a temporary improvement. Three other residents have developed a similar eruption
scabies
An 18 year old black West Indian man presents with painful joints. He has a high temperature and complains of repeated chest infections. On examination his sclerae are slightly yellow. Urine Dipstix shows blood and protein in small amounts.
sickle cell disease
what cerebral palsy is most associated with intraventricular haemorrhage
spastic diplegic
A 31-year-old female with no past medical history of note is admitted to hospital with dyspnoea and fever. She has recently returned from holiday in Turkey. A clinical diagnosis of pneumonia is made. On examination she is noted to have an ulcerated lesion on her upper lip consistent with reactivation of herpes simplex. Which organism is most associated with this examination finding?
streptococcus pneumonia- can cause herpes labialis
A 27-year-old female presents with weakness of both hands. On examination you note wasting and weakness of the small muscles of the hands and loss of pain and temperature sensation over the trunk and arms. Vibration sense is intact. What is the most likely diagnosis?
syringomyelia Syringomyelia is a condition whereby fluid filled cavities develop within the spinal cord. Pressure can increase resulting in compression of the spinal cord tracts. The syrinx can extend to and damage the anterior horn cells, thereby resulting in lower motor neurone features. The spinothalamic tract axons decussate to the other side of the spinal cord via the anterior white commissure, and they are particularly susceptible to damage from the syrinx. Pain and temperature sensation are lost due to spinothalamic tract damage, and one side may be affected more than the other. Classically, the sensation loss is experienced in a shawl-like distribution over the arms, shoulders and upper body. Light touch, vibration and proprioception may also be affected as the syrinx enlarges into the dorsal columns.
name 3 cyanotic congenital heart defects
tetraology of fallot -1-2 months tricuspid atresia transposition of great arteries- more common at birth
A 72-year-old man is brought to clinic by his family. They are very concerned about his declining cognition. He was normally very well and independent until 3 months ago. He has lost no weight, has no headache but has been falling a lot. He also complains of urinary incontinence.
the clinical features are very suggestive of normal pressure hydrocephalus. The features of this condition can be remembered by 'wet, wobbly and whacky' which represent urinary incontinence, gait ataxia, and dementia respectively. Imaging hydrocephalus with an enlarged fourth ventricle Management ventriculoperitoneal shunting
what is the reason for iodine uptake and gamma scan
to distinguish between the causes of hyperthyroidism
A primigravid 43 year-old woman, who is at 27 weeks gestation, presents to the maternity unit with regular weak contractions. Examination reveals her cervix is 3 cm dilated and membranes are intact. What would be the most appropriate management?
tocolytics to try and stop the pregnancy and steroids should be given in case premature labour then decrease the risk of respiratory distress sysndrokme
A 2-year-old child comes in too see you with his mother at the GP surgery. The mother tells you that for the past few months the child has been suffering from diarrhoea. On further questioning she denies that it is foul smelling but does confirm it sometimes contains undigested food. There are no other symptoms such as abdominal pain or bloating. You plot their height and weight and it is appropriate for their age. What's the most likely diagnosis?
todler's diarrhoea just fast trasnit of the go system can contain undigested food
treatment for acromegaly medical
transphenoidal surgery is normally first line for every patient, but medical treatment can include octeotride-somatostatin analgoues which stop the production of growth hormone but can also use bromcriptine but not as effective
what is the most useful blood test for hyperthyroidism
tsp level
An 85 year old woman presents to the Accident and Emergency Department following a collapse whilst standing in a queue
vasovagal syncope
A 52-year-old man presents with a 5 day history of cough, feeling hot and facial pains. He is generally fit and well although does currently take sertraline for anxiety and depression. He describes a cough productive of pale yellow sputum. He also describes difficulty breathing through his nose and pain in his face, particularly when coughing on leaning forward. On examination he is alert, pulse rate is 84/min, temperature is 37.3º and respiratory rate is 16/min. His blood pressure is 122/74 mmHg. Chest auscultation is unremarkable. He is tender over the maxilla. What is the most appropriate next step in management?
viral upper respiratory tract infection- facial pain due rhinosinusitis just give paracetamol and review in a few days
congenital heart defects ventricular septal defect coarctation of the aorta patent ductus aortiosus pulmonary stenosis
vsd- pansystolic murmur in the lower left sternal border coa- crescendo-decrescendo of the murmur in the upper left sternal border machinery murmur upper left sternal border pulmonary stenosis- ejection systolic murmur in the upper left sternal border asd
