BOF
BOF 1 A 68-year-old female patient is seen on the ward. She complains of severe pain in her right eye. There is blurring of vision and she feels nauseated and has vomited several times. Earlier in the day she has undergone colonoscopy for evaluation of her long-standing Crohn's disease. The endoscopist has made a comment that the examination was difficult. What is the likely cause of her painful red eye?
a) Anterior uveitis
b) Acute conjunctivitis
c) Episcleritis
d) Sub-conjunctival haemorrhage
e) Acute angle closure glaucoma
Answer e) Anticholinergic agents are sometimes used during endoscopy to cause smooth muscle relaxation to aid examination when difficulty is encountered. These agents cause pupillary dilatation thus precipitating acute angle closure glaucoma in susceptible patients. In patients with a history of glaucoma, glucagon is used instead of anticholinergics.
BOF 2 The surgical registrar on duty calls you up to ask for advice. A 24-year-old female patient was admitted under their care the previous night and underwent a diagnostic laparoscopy for investigation of abdominal pain. The examination was normal, the pain has subsided and the plan is to discharge the patient. The patient is a tourist and wants to travel back to her home country. He would like to know how soon after laparoscopy a patient might undertake an airline flight. What would your reply be?
a) Immediately
b) After one week
c) After five days
d) 48 hours
e) Ten days
Answer: d) Modern aircraft normally cruise at between 35,000 to 43,000 feet. As this environment would be non-physiological, the aircraft cabin is pressurised to a maximum cabin altitude of 8,000 feet. This reduced atmospheric pressure would cause gas in body cavities to expand by 30-40%. Hence, air travel should be delayed for 48 hours after laparoscopy to allow all gas to be absorbed.
BOF: 3 A 55-year-old male is admitted as an emergency with severe abdominal pain. He smokes 30 cigarettes a day and takes approximately 30 units of alcohol per week but admits to exceeding this amount sometimes. He also complains of sudden deterioration in vision. Ophthalmoscopy shows multiple micro infarcts (cotton wool spots). What investigation would best confirm your diagnosis and guide treatment?
a) Upper GI endoscopy
b) E.R.C.P.
c) Blood glucose
d) Mesenteric angiogram
e) CT scan abdomen
Answer: e)Ischaemic retinopathy, which causes retinal oedema and micro infarcts, causes acute visual loss. This is a complication of acute pancreatitis. CT scanning will be useful in diagnosis and evaluation of pancreatitis
BOF: 4 A patient has been transferred to your ward from the coronary care unit. He has suffered an uncomplicated myocardial infarct 3 days ago and at the moment he has no problems. He is a tourist and wishes to travel back home as soon as possible. How soon after an uncomplicated myocardial infarct may a patient undertake air travel safely?
a) 10 days
b) 48 hours
c) 72 hours
d) 14 days
e) 21 days
Answer: a) A patient should be fit to fly 10 days after an uncomplicated myocardial infarct.
BOF: 5A 32-year-old female patient has had multiple resections of the bowel on account of recurrent Crohn's disease. This has resulted in intestinal failure and she is dependent on home parenteral nutrition. She has a Broviac catheter inserted for central venous access. She presents with fever accompanied by chills and rigors.
No physical signs are demonstrable. Cultures taken both centrally and peripherally demonstrate the presence of methicillin-sensitive Staphylococcus aureus.
Your next course of action would be
a) Treatment with intravenous vancomycin for 14 days followed by repeat cultures
b) Treatment with intravenous teicoplanin for 14 days followed by repeat cultures
c) Determine the antibiotic sensitivity prior to commencing antibiotic treatment
d) Do not use the intravenous line until the infection has been successfully eradicated.
e) Remove the intravenous line
Answer e) One of the main complications of parenteral nutrition is infection of the central line. Educating the patient and carers may reduce this. However, line infections do occur and infection with Staphylococcus aureus and Candida are indications for line removal.
BOF: 6 A 76-year-old male has been admitted to your ward following a stroke that has resulted in a left hemiplegia. He is a mild diabetic and is hypertensive but both these conditions are well controlled. Seven days after admission the patient develops fever, tachycardia and tachypnoea. On auscultation of his chest crepitations are heard over both lung bases. Chest X-ray demonstrates bilateral basal pulmonary infiltrates. Your decision regarding empirical antibiotic treatment for this condition will be based on the assumption that the most likely causative organisms would be
a) Methicillin-resistant Staphylococcus aureus
b) Methicillin-sensitive Staphylococcus aureus
c) Pneumococcus
d) Gram-negative organisms
e) Legionella
Answer d) The diagnosis in this patient is most likely to be hospital-acquired pneumonia. After taking appropriate cultures, the patient should be started on antibiotics.Gram-negative organisms are the most likely cause of hospital-acquired pneumonia. Pneumococci are seldom isolated from culture and the most common gram-positive organism that causes hospital-acquired pneumonia is Staphylococcus aureus, particularly MRSA
BOF: 7 A soldier returns from training in Belize. He has developed an ulcer on his right leg that has failed to heal despite treatment with antibiotics and daily dressings. Skin biopsy from the edge of the lesion has been examined histologically and amastigotes have been detected.
Your next course of action would be.
a) Leave the lesion alone and await spontaneous healing.
b) Freeze the lesion with liquid nitrogen
c) Treat the patient with a twenty-day course of sodium stibogluconate
d) Surgical excision
e) Intralesional injection of sodium stibogluconate
Answer c) Amastigotes (LD) bodies seen on biopsy suggest the diagnosis of Leshmaniasis. Cutaneous leishmaniasis may be divided into that of the Old World (Africa, Mediterranean, Afghanistan) and cutaneous leishmaniasis of the New World (Central and South America). Cutaneous leishmaniasis of the Old World heals in 4-18 months leaving a scar. No serious sequelae occur. It may be left alone. It could be frozen with liquid nitrogen. A pentavalent antimonial such as sodium stibogluconate may be administered intralesionally. Cutaneous leishmaniasis of the New World runs a more protracted course. Without treatment the ulcers may persist for years. Some of the patients may develop the mucocutaneous form where the infection spreads from the skin the nasopharyngeal mucosa and this leads to progressive destruction of the nose and pharynx. New World cutaneous leishmaniasis should be treated and the drug used is sodium stibogluconate.
BOF: 8 One of your patients suffers from a cardiac arrhythmia that gives rise to syncope. He continues to drive despite you having made all reasonable efforts to explain to him that this is unsafe. Your response should be
a) It is the legal obligation of the patient to inform the authorities of his disability; hence you are not obliged to take any further action
b) As the patient has a right to confidentiality you may not take the matter any further
c) Inform the police
d) Inform the next of kin or the driving authority
e) Inform the patient's solicitor
Answer: d) In such a situation your duty to society overrides any right of an individual to confidentiality. The ultimate responsibility is yours and you have to inform the next of kin or the driver licensing authority.
BOF: 9 A 26-year-old male has returned from a backpacking trip to India. It is a week since arriving back in Britain. He has had fever for two weeks and has been treated with an antibiotic for a few days whilst in India. He does not know the name of the drug used.On examination he is febrile, has a few rose spots on his abdomen and splenomegaly.What source is the most likely to provide a positive culture in view of the fact that he has been exposed to antibiotics?
a) Blood
b) Rose spots
c) Bile
d) Urine
e) Bone marrow
Answer: e) In typhoid fever, positive cultures may be obtained from blood, bone marrow, urine, faeces, rose spots and bile.Bile has a high concentration of bacteria and the method of culturing it is by using a duodenal string capsule to obtain intestinal fluid. Bone marrow gives a good yield on culture and may provide culture even after antibiotic treatment has been commenced.
BOF: 10 A fifty-year-old patient attending the hypertension clinic has refractory hypertension. Random aldosterone: plasma renin activity has shown a ratio of greater than 750. In order to differentiate the underlying cause of primary aldosteronism, demonstrated in this patient, you arrange for the patient to have aldosterone: plasma renin activity measured in the morning (at 8 a.m.) with the patient in the supine position and again at noon with the patient in the erect position. This test helps to differentiate the causes of primary hyperaldosteronism because
a) ACTH suppresses aldosterone secretion in adrenal adenoma
b) ACTH has no effect on glucocorticoid suppressible hyperaldosteronism
c) Erect posture increases plasma aldosterone in adrenal hyperplasia
d) ACTH levels are higher at noon
e) The supine position increases aldosterone secretion in glucocorticoid suppressible hyperaldosteronism.
Answer: c)In primary aldosteronism, the aldosterone: PRA (plasma renin activity) ratio is greater than 750.
The causes of primary aldosteronism are
• An aldosterone producing adenoma (Conn's syndrome)
• Bilateral adrenal hyperplasia
• Glucocorticoid suppressible hyperaldosteronism
• Adrenal carcinoma (rare)
• Unilateral hyperplasia (rare)
By measuring aldosterone: PRA ratio at 8a.m. in the supine position and at noon in the erect position one may differentiate between these conditions. Posture has an effect on aldosterone levels in adrenal hyperplasia. Erect posture increases plasma aldosterone. ACTH produces a marked effect in patients with glucocorticoid suppressible hyperaldosteronism.It increases aldosterone levels.ACTH has no effect in adrenal hyperplasia ACTH has only a small effect on adrenal adenoma At 8a.m. ACTH levels are higher than at noon.
BOF: 11 A 32-year-old male has returned from a holiday in Gambia six weeks ago.He presents with fever, chills and rigors and on clinical examination is found to have an enlarged spleen. Initial thin film examination for malarial parasites is negative.You are aware that local experience and expertise in diagnosing malaria is not dequate.As the clinical suspicion of malaria is very high in this patient, what would your next course of action be?
a) Repeat the thin film examination in 48 hours
b) Do a thick film examination
c) Do a dipstick assay of Plasmodium Lactate dehydrogenase (pLDH)
d) Give empirical treatment for malaria
e) Repeat thick and thin films in 72 hours
Answer: c)In patients with malaria, examination of a thin film is useful for making the diagnosis of the particular type of malaria and assessing the degree of parasitaemia. However, this depends on local expertise.If an initial film is negative it is best to repeat the test in 12 hours and then again in 24 hours if still negative.Thin films are more sensitive than thick films but this depends on the expertise of the person performing the examination.Dipstick assay is available for detection of all four types of malaria.The assay can differentiate between P.falciparum and P.vivax The test is an antigen detection system for Plasmodium Lactate Dehydrogenase (pLDH) p LDH is an abundant intracellular enzyme produced by malarial parasites. The dipstick is coated with monoclonal antibodies against this intracellular metabolic enzyme pLDH.The test is effective, sensitive and may be performed rapidly.It has almost the same sensitivity as examination of a thick film by an expert. It should be used as a supplement to thin film examination where expertise is lacking.
BOF: 12 A 60-year-old male is admitted with a history of acute on chronic breathlessness. He has been a longstanding smoker. On examination, he is breathless at rest with pursed lip breathing, use of accessory muscles of respiration and a barrel shaped chest. He is not oedematous.Which of the following physical signs will allow you to infer that on chest X-ray hyper inflated lung fields will be seen?
a) Determining respiratory movements
b) Vocal fremitus
c) Percussion
d) Auscultation of breath sounds
e) Vocal resonance
Answer:c) Absence or reduction of dullness over the praecordium (cardiac dullness) or reduction of dullness over the right lower chest (liver dullness) will allow you to infer that on chest X-ray the lung fields will be hyper inflated.
BOF: 13 A 56-year-old male presents with pain in the lower back. The pain has a girdle like distribution beginning in the lower back and radiating to the lower bdomen. He has not been on any drugs. The patient is hypertensive but there are no other physical signs of note. Investigations reveal a normocytic normochromic anaemia, raised erythrocyte sedimentation rate and C-reactive protein. Renal function is impaired. Ultrasound scanning reveals bilateral hydronephrosis. Which of the following investigations is most likely to give you the diagnosis?
a) Intravenous urogram
b) Retrograde urogram
c) Isotope renogram
d) Computerised tomogram of abdomen
e) Renal biopsy
Answer: d) The patient has idiopathic retroperitoneal fibrosis (peri-aortitis).This is a condition in which the ureters become embedded in dense fibrous tissue, usually at the junction of the middle and lower thirds of the ureters.This results in unilateral or bilateral ureteric obstruction.CT scanning will show a peri-aortic mass.Histological confirmation is obtained by CT guided biopsy or laparotomy.
BOF: 14 A 54-year-old male has a longstanding cough productive of sputum and breathlessness on exertion. The breathlessness increases following upper respiratory tract infections. He has been smoking 20 cigarettes a day over a period of 30 years.On examination, there is no clubbing the patient is breathless with use of accessory muscles and resting activation of the abdominal muscles. The chest is barrel shaped and cardiac dullness is reduced. Breath sounds are reduced on auscultation and a few rhonchi are audible.In your assessment of the patient which one of the following is known to be a predictor of mortality?
a) The degree of breathlessness
b) The presence of pursed lip breathing
c) The body mass index (BMI)
d) Spirometry
e) Blood gas analysis
Answer: c) The patient has chronic obstructive pulmonary disease.A low body mass index is a known predictor of mortality in patients with chronic obstructive pulmonary disease. A change in BMI with treatment suggests a better prognosis.Ankle swelling is also an important prognostic feature. This is because ankle swelling suggests the development of right ventricular failure.
BOF: 15 A 54-year-old male with known chronic obstructive pulmonary disease is breathless on minimal exertion and is almost incapacitated by this. Chest X-ray has demonstrated the presence of large emphysematous bullae. In this patient you would arrange a CT scan of his chest for the following reason.
a) To exclude a co-existent lung cancer
b) To exclude co-existent heart failure
c) To document the presence of bronchiectasis
d) To determine the distribution of the emphysema
e) To detect co-existent pulmonary emboli
Answer: d) This patient has incapacitating chronic obstructive pulmonary disease and has emphysematous bullae.This patient will be considered for lung volume reduction surgery.The distribution of the emphysema is an important variable when lung olume reduction surgery is being considered
BOF: 16 A 63-year-old male presents with a history of itching after he has a hot shower. There are no other clinical features of note. He has no significant past illnesses and is not taking any medication. Which of the following investigations is most likely to lead you to a diagnosis?
a) Alkaline phosphatase levels
b) Blood urea and electrolytes
c) Thyroid stimulating hormone levels
d) The fasting blood glucose levels
e) A Full Blood Count
Answer: e) Aquagenic pruritus is caused by the slow release of histamine when the skin is exposed to water.The slow rate of release of histamine gives a sufficient concentration to cause itch but is insufficient to cause visible vascular changes. Aquagenic pruritus is a feature of Polycythaemia Rubra Vera but may also occur in conditions such as Hodgkin's disease and myeloid metaplasia.Out of the choices given, the full blood count will pick up this haematological condition, which is the most likely cause of this type of pruritus in a male in this age group.Remember that Aquagenic pruritus may precede the development of Polycythaemia Rubra Vera by several years.
BOF: 17 A 25 year old male who is known to have insulin dependent diabetes mellitus presents with nausea, vomiting and abdominal pain. He has a tachycardia, a postural drop in blood pressure. He is hyperglycaemic and has ketonuria. The clinical feature that will help differentiate abdominal pain due to diabetic ketoacidosis from a surgical emergency is:
a) Postural hypotension
b) The presence of diarrhoea
c) Abdominal pain preceding the onset of vomiting
d) Vomiting preceding the onset of abdominal pain
e) Colicky pain in the right iliac fossa
Answer: d)Abdominal pain may be a feature of diabetic ketoacidosis. It is usually a dull, persistent discomfort centred on the umbilicus. If vomiting precedes the onset of abdominal pain it is more likely to be due to ketoacidosis than to be a surgical mergency.
BOF: 18 Inferior extension of a pituitary tumour may result in
a) Ethmoid sinusitis
b) Sphenoid sinusitis
c) Damage to the maxillary division of the trigeminal nerve
d) Sixth nerve palsy
e) Quadrantic hemianopia
Answer: b)The inferior relationship of the pituitary is the sphenoid sinus and rarely inferior extension of a pituitary tumour may result in sphenoid sinusitis.
BOF:19 An obese 45-year-old female is referred to the clinic by her general ractitioner as she has been found to have a raised alanine aminotransferase level. She is not on any medication and does not take alcohol. On examination she is obese. In this patient you would expect:
a) Type 2 diabetes mellitus
b) Insulin resistance
c) Hyperlipidaemia
d) Acanthosis nigricans
e) Hepato-splenomegaly
Answer: b) This patient has non-alcoholic fatty liver disease. The metabolic abnormalities leading to accumulation of lipid within hepatocytes are poorly understood but one of the most reproducible features in the development of this process is insulin resistance. Type 2 diabetes mellitus and hyperlipidaemia frequently co-exist with this condition but not necessarily.Acanthosis nigricans is a feature of non-alcoholic fatty liver in children. Hepatomegaly is a common finding but not hepato-splenomegaly.
BOF: 20 A 45-year-old female being treated for rheumatoid arthritis is admitted complaining of breathlessness on exertion. She is found to have a Haemoglobin level of 8.5 g/dl with a MCV of 102. The white cell count and platelets are normal.The anaemia is most likely to be due to:
a) Treatment with Diclofenac
b) Treatment with methotrexate
c) Anaemia of chronic disease
d) Treatment with penicillamine
e) Felty’s syndrome
Answer: d) Treatment with non-steroidal anti-inflammatory drugs would result in anaemia as a consequence of gastro-intestinal haemorrhage. This would cause a microcytic hypochromic anaemia if chronic or normocytic normochromic anaemia if acute. Methotrexate treatment would result in marrow aplasia and a pancytopaenia Anaemia of chronic disease would result in normocytic normochromic anaemia. In Felty’s syndrome the patient would be neutropaenic.Treatment with penicillamine could result in haemolytic anaemia with macrocytosis.
BOF: 21 A 33-year-old female who has had multiple resections of the small bowel has been left with 90 cms of jejunum anastamosed to the colon. She is maintained on a diet high in polysaccharides and manages well on this diet. She is admitted to the ward with ataxia, blurred vision, ophthalmoplegia and nystagmus.The likely cause of this complication is
a) Thiamine deficiency
b) Vitamin B 12 deficiency
c) Magnesium deficiency
d) L (+) lactic acidosis
e) D (-) Lactic acidosis
Answer: e) In patients with a short small bowel and an intact colon, energy is absorbed from the colon by bacterial fermentation of polysaccharides to short chain fatty acid, which can be absorbed by the colonocytes. In rare instances mono and oligosaccharides may be metabolised to D (-) lactic acid by abnormal bacteria. The normal lactic acid produced by man is L (+) lactic acid. Absorption of D (-) lactic acid results in ataxia, blurred vision, ophthalmoplegia and nystagmus. Treatment is with broad-spectrum antibiotics such as neomycin or vancomycin, thiamine and a change in diet to one high in polysaccharides and low in mono and oligosaccharides.
BOF: 22 A 28-year-old male presents with a painful swollen knee. He feels generally unwell and has fever. He has a psoriasiform rash on his glans penis and he also complains of low backache. Six weeks previously he has had a self-limiting episode of diarrhoea.In this patient
a) Prompt treatment will reduce the chance of recurrence
b) High dose steroids should be used without delay
c) Prolonged antibiotic treatment will prevent the disease becoming chronic
d) If the disease becomes chronic sulphasalazine and methotrexate are useful second line agents
e) He has a greater than 50 % chance of developing erosive disease or spondylitis
Answer: d) This patient has developed reactive arthritis. If possible athrocenetesis should be preformed to exclude septic arthritis. Prednisolone does help to control symptoms in active disease but is not the drug of first choice. Non-steroidal anti-inflammatory drugs should be used. Antibiotics should be used if active infection is demonstrated but prolonged therapy is of no benefit. More than 50 % of patients will experience further episodes. Sulphasalazine and methotrexate are useful second line agents if the disease becomes chronic. About 15 % of patients go on to develop erosive disease or spondylitis.
BOF: 23 A 35-year-old female presents with a mutilating arthritis of the hands with associated pitting of the nails.In treating this patient
a) Sulphasalazine is unlikely to be effective
b) Methotrexate is unlikely to be effective
c) Antimalarials are best avoided
d) Tumour necrosis factor alpha antagonists are not effective
e) Oral corticosteroids should be the drugs of first choice as they help the nail condition as well
Answer: c) The patient has psoriatic arthropathy. Treatment is usually with non-steroidal anti-inflammatory drugs although there is a risk of worsening the psoriasis. Sulphasalazine and methotrexate are useful in this condition. Tumour necrosis factor alpha antagonists are effective but are expensive to use. Steroids are seldom needed and may provoke worsening of the psoriases on withdrawal. Antimalarials are best avoided as they can cause an acute psoriatic skin reaction.
BOF: 24 A 45-year-old male presents with a sudden onset of pain and swelling of the metatarso-phalangeal joint of the right big toe. In this patient
a) A normal serum uric acid concentration excludes the diagnosis of gout
b) The x-ray changes would be characteristic
c) Synovial fluid analysis should be delayed to allow crystals to aggregate and become easier to visualise
d) Fever, leucocytosis and elevated ESR would suggest septic arthritis
e) The first attack is seldom associated with residual disability
Answer: e) In an acute attack of gout serum uric acid is raised in only about 60 % of patients. Similar x-ray changes may occur in inflammatory and degenerative arthritis. Synovial fluid analysis should be undertaken immediately following aspiration of joint fluid. The characteristic changes being the demonstration of needle shaped negatively birefringent crystals of mono-sodium urate in synovial fluid neutrophils by polarizing light microscopy. A raised ESR fever and leucocytosis can accompany very acute attacks of gout and do not necessarily indicate sepsis. The first attack of gout is seldom associated with residual disability.
BOF: 25 A sixty five year old male who is on treatment for chronic heart failure with diuretics, angiotensin converting enzyme inhibitors, beta-blockers and spironolactone presents with sudden onset of pain and swelling of the metatarso-phalangeal joint of his right big toe. Aspiration of the joint demonstrates crystals of monosodium urate.
In this patient:
a) Moderate doses of aspirin would be beneficial
b) Non-steroidal anti-inflammatory digs would be the drugs of first choice
c) Highly selective cyclooxygenase 2 inhibitor should be used
d) Colchicine would be the best choice
e) Parenteral colchicine may be safely used to counter nausea and diarrhoea
Answer: d) Aspirin unless used in high doses causes uric acid retention. Non-steroidal anti-inflammatory drugs would be contraindicated in view of the heart failure. Highly selective COX 2 inhibitors may not be used with co-existing heart failure. Intravenous colchicine is potentially hazardous.
BOF: 26 A 50-year-old female presents with a sudden onset occipital headache followed by a decreased level of consciousness. On examination she has neck tiffness and a positive Kernig’s sign. CT scanning shows blood in the sub-arachnoid and intraventricular space. The patient improves initially but 10 days following admission her level of consciousness begins to deteriorate. The next step in management would be:
a) Decompression by lumbar puncture
b) Lumbar puncture followed by high dose broad spectrum antibiotics until cultures are available
c) High dose dexamethasone
d) CT scan followed by a ventricular jugular shunt
e) Cisternal puncture for decompression
Answer: d) The patient has had a sub-arachnoid haemorrhage. Deterioration coming on after an initial improvement is most likely due to the development of secondary hydrocephalus due to blockage of CSF flow by blood. The management would be CT scan to confirm the diagnosis followed by a procedure to drain CSF.
BOF: 27 A 60-year-old female presents with a severe left-sided temporal headache. The temporal artery is tender, pulsation is lost and the overlying skin is erythematous. The E.S.R. is 80 mm in the first hour. In this patient:
a) A short course of high dose steroid should be prescribed
b) The E.S.R. is not a reliable guide to use when reducing the dosage of steroids
c) The headache subsides within hours of commencing the patient on high dose steroid
d) Lifelong steroid treatment will be required
e) As steroids may be harmful in elderly patients, treatment should be delayed until the results of temporal artery biopsy are available
Answer: c) The patient has temporal arteritis. The diagnosis is confirmed by biopsy but in view of the serious complications that may occur treatment with high-dose steroids should be started immediately. Reduction of steroid dosage is guided by the fall in the E.S.R. but the duration of treatment would be several months to years.
BOF: 28 A 30-year-old female presents with a history of weakness and fatigability of the ocular, bulbar and limb muscles. On examination she has bilateral ptosis and extra-ocular muscle weakness. Reflexes are preserved, there is no muscle wasting. The Edrophonium test is positive. In this patient
a) Thymectomy has no long term benefit
b) If a thymoma is present the muscle weakness would improve
c) In non-thymoma patients improvement will be seen in 60 % of patients
d) The prognosis is worse as the patient is under 40 years of age
e) Thymectomy should not be performed if the patient has positive receptor antibodies
Answer: c)In myasthenia gravis thymectomy offers long-term benefits. It improves the prognosis in patients below 40 years, in those with positive receptor antibodies and in those who have had the disease for less than 10 years. Following thymectomy 60 % of non-thymoma patients will improve. In thymoma although surgery is necessary as the tumour is potentially malignant, the myasthenia is unlikely to improve.
BOF: 29 A 70-year-old male is referred by his general practitioner as he has had a stroke. On examination the patient has left sided complete third nerve palsy with a contralateral hemiplegia. The lesion is likely to be in the:
a) The pons
b) The medulla
c) The mid-brain at the level of the inferior colliculus
d) The mid-brain at the level of the superior colliculus
e) The thalamus
Answer: d) The lesion involves the mid-brain at the level of the superior colliculus damaging the third nerve nucleus and the cerebral peduncles.
BOF: 30 A 30-year-old male presents with a chronic cough productive of copious amounts of thick yellow sputum and occasional haemoptysis. He also complains of bad breath and recurrent episodes of fever. On examination he has clubbing and on auscultation over the lung bases coarse crepitations are heard. The test that would identify the cause of his condition would be:
a) Sweat electrolytes
b) Sinus x-ray
c) Bronchoscopy
d) High resolution CT scanning
e) Bronchography
Answer: d) The patient has bronchiectasis. High resolution CT scanning would be the investigation of choice. It would show bronchial dilatation and wall thickening.
BOF: 31 A 30-year-old female presents with fatigue, weight loss, red, painful tender nodules over her shins and breathlessness. The chest X-ray shows bilateral hilar lymphadenopathy. Investigations show that she has hypercalcaemia.The cause of the hypercalcaemia is:
a) Increased parathyroid hormone production in the lungs
b) A high serum ACE causing increased hydroxylation of 25 hydroxycholecalciferol to 1,25 dihydroxycholecalciferol in the kidney
c) Alpha hydroxylation of 25 hydroxycholecalciferol to 1, 25 dihydroxycholecalciferol by macrophages in the lung
d) Lytic lesions in the bones
e) Hyperventilation
Answer: c) The patient has sarcoidosis. In this condition alpha hydroxylation of 25 hydroxycholecalciferol to 1,25 dihydroxycholecalciferol takes place in sarcoid macrophages in the lungs. This increases levels of calcitriol in the blood and results in hypercalcaemia.
BOF: 32 A 65-year-old male presents with a chronic cough. He is a heavy smoker of over 40 cigarettes a day. CXR shows a peripheral right-sided lesion, which on CT guided lung biopsy, is shown to be squamous carcinoma. No regional lymph nodes are involved. Lung function tests show a FEV1 of less than 1.5 litres. The treatment most likely to benefit this patient would be:
a) Surgery
b) Chemotherapy
c) High dose radiotherapy
d) Combination chemotherapy and radiotherapy
e) Combination chemotherapy and surgery
Answer: c) A FEV1 of less than 1.5 litres is not compatible with an active life following surgery. High dose radiotherapy can produce good results and is the treatment of choice in patients with poor lung function.
BOF: 33 A 45-year-old male homeless alcoholic has been referred to the medical ward after being brought in to casualty. He has a chronic cough productive of sputum, loss of weight, and night sweats. On examination he is unkempt and emaciated. His trachea is deviated to the left and there are crepitations over the apex of the left lung. CXR shows fibrosis and cavitation in the left apex. The investigation most likely to confirm the diagnosis would be
a) Sputum examination for acid and alcohol fast bacilli
b) High resolution CT scan
c) Fibreoptic bronchoscopy
d) Mantoux test
e) Gastric washings
Answer: a) The patient has a productive cough. The chances are that AAFB will be identified in these specimens. If sputum were not produced bronchoscopy would be preferred to gastric washings.
BOF: 34 A fifty –five year old male presents with a history of anorexia, nausea and vomiting and abdominal pain. His skin is pigmented with pigmentation of palmar creases and sun exposed areas. He has a few patches of vitiligo. His blood pressure is low and there is a postural drop. In this patient the blood urea and electrolytes are likely to show the following
a) Decreased Na, Decreased K, Normal Urea
b) Decreased Na, Increased K, Increased Urea
c) Decreased Na, Increased K Normal Urea
d) Increased Na, Decreased K, Increased Urea
e) Decreased Na, Decreased K, Increased Urea
Answer: b) The patient has Addison’s disease. The Na will be low with and increase in K and increase in blood urea.
BOF: 35 A sixty-year-old female presents with a history of palpitations and swelling in the neck. On examination of the pulse there is atrial fibrillation and in the neck there is a large multinodular goitre. In this patient which one of the following are likely
a) Eye signs are common
b) Eye signs are rare
c) Spontaneous remission is likely
d) Long term antithyroid drugs are effective in controlling symptoms
e) Thyroxine will help to reduce the size of the goitre
Answer: b) This patient has toxic multinodular goitre. In this condition eye signs are rare unlike Grave’s disease. Spontaneous remission is rare. Antithyroid drugs will increase the size of the goitre and are only used as a temporary measure prior to definitive treatment. Thyroxine will not reduce the size of the goitre.
BOF: 36 A sixty-year-old female presents with a history of nausea, lethargy and depression.Her skin is pigmented and there is vitiligo. Her blood pressure is low and there is a postural drop. In this patient which one of the following are true
a) Eosinopaenia is a feature
b) The ESR is decreased
c) Hyperglycaemia is a feature
d) The heart size is small
e) Hypokalaemia would occur
Answer: d) The patient has Addison’s disease. In this condition the heart size is small. The eosinophil count may be elevated, the ESR may be high, hypoglycaemia may be a feature, and hypokalaemia would be a feature.
BOF: 37 A sixty-year-old man presents with a history of increased sweating. He also complains of headaches.On examination the patient has large hands and the facial features are exaggerated with large nose, prominent jaw and thick lips.In this patient which of the following may be used as a screening test
a) Growth hormone level
b) Glucose Tolerance Test
c) Prolactin level
d) Plasma Insulin-like Growth Factor levels
e) Serum calcium
Answer: d) The patient has acromegaly. Plasma Insulin-like Growth Factor may be used as a screening test.
BOF: 38 A fifty-five year old man is admitted with a history of fatigue, weight loss and jaundice. His alcohol intake is sixty units a week. On examination he has clubbing, Dupuytren’s contracture, palmar erythema, flapping tremor, parotid enlargement, spider naevi, gynaecomastia, hepatosplenomegaly.Which of the following signs is indicative of a poor prognosis:
a) Clubbing
b) Parotid Enlargement
c) Gynaecomastia
d) Flapping Tremor
e) Splenomegaly
Answer: d) The patient has alcoholic liver disease with clinical evidence of cirrhosis. The features of a poor prognosis are hepatic encephalopathy, low serum albumin concentration, and low serum sodium and prolonged prothrombin time.
BOF: 39 A sixty-year-old man who is known to have ischaemic heart disease is admitted with a history of sudden onset abdominal pain, followed by watery diarrhoea and subsequent profuse rectal bleeding. The likely diagnosis is
a) Small bowel infarction
b) Large bowel infarction
c) Volvulus of the sigmoid colon
d) Colon cancer with intussusception
e) Ulcerative colitis
Answer: b) The history of pain flowed by diarrhoea and bleeding per rectum in a patient with known macro vascular disease is typical of large bowel infarction, which occurs in the region of the splenic flexure.
BOF: 40 A thirty five year old female has had a right hemicolectomy and resection of 30 cms of terminal ileum for ileocaecal Crohn’s disease. She has persistent diarrhoea, which is not explosive. She does not have abdominal pain, bloating, or loss of weight. Investigations have failed to demonstrate evidence of recurrent Crohn’s disease. Treatment that would relieve symptoms and give a clue to the underlying diagnosis would be:
a) Loperamide
b) Steroids
c) Cyclical antibiotics
d) Cholestyramine
e) Tricyclic antidepressants
Answer: d) The patient has had resection of the terminal ileum and the cause of the diarrhoea is likely to be Bile Acid Malabsorption (BAM). Treatment with a Bile Acid Sequestrants such as Cholestyramine would relieve symptoms and point to the diagnosis.
BOF: 41 A thirty four year old female presents with a deep vein thrombosis. She has a history of weight loss, recurrent mouth ulcers and chronic diarrhoea with the passage of a bulky stool, which is difficult to flush away. She has a macrocytic anaemia.The underlying biochemical abnormality that would explain the DVT would be:
a) Vitamin B 12 deficiency
b) Folic acid deficiency
c) Iron deficiency
d) Protein S deficiency
e) Protein C deficiency
Answer: b) The patient has coeliac disease. In coeliac disease folic acid deficiency with resultant hyper-homocystinaemia increases the tendency to thromboembolic phenomena.
BOF: 42 A twenty seven year old female presents with a rash. The rash consists of erythematous plaques, excoriations, and vesicles some of which have ruptured leaving a crust.She also complains of diarrhoea with the passage of a bulky stool, which is difficult to flush away. In this patient:
a) The rash responds rapidly to a gluten free diet
b) The rash responds slowly to treatment with Dapsone
c) The rash responds rapidly to treatment with Dapsone
d) Doxycycline is the drug of choice
e) Oral Steroids should be commenced immediately
Answer: c) The patient has dermatitis herpetiformis, which is associated with coeliac disease. The rash responds within a few hours to treatment with dapsone.
BOF: 43 A twenty four year old female who is known to have ulcerative colitis presents with an ulcer above the medial malleolus. This is large has a necrotic base and the edges are undermined. In this patient:
a) Immediate treatment should be with broad spectrum antibiotics
b) High dose steroids should be used in the first instance
c) Surgery is the first line treatment of the ulcer
d) Treatment of the colitis with high dose mesalazine preparation will cause the ulcer to heal
e) Colectomy is indicated
Answer: b) The patient has pyoderma gangrenosum complicating ulcerative colitis. The initial treatment should be with high dose steroids.
BOF: 44 A 50-year-old male presents with oral ulceration, and flaccid blisters on the skin especially the trunk. The blisters are sore but not itchy and they rapidly denude leaving weeping, erythematous erosions. Gentle sliding pressure on the blisters makes them extend. In this condition:
a) Low dose steroids are effective in controlling formation of new blisters
b) Local steroids are effective in controlling the disease
c) Long term tetracycline is effective treatment
d) Gold may be effective therapy in steroid resistant patients
e) Dapsone is effective on controlling the disease
Answer: d) The patient has pemphigus vulgaris. The physical sign described is Nikolsky's sign( extension of the blister with pressure). In pemphigus vulgaris high dose steroids may be needed to prevent formation of new blisters. Azathioprine and methotrexate may be needed to reduce the dose of steroids. Gold may be effective in steroid resistant patients.
BOF: 45 In patients with cystic fibrosis a FEV1 of less than 30 % would predict
a) 80% of patients would be infected with Pseudomonas aeroginosa
b) 60% would develop a digestive tract malignancy
c) 80 % would develop a variceal haemorrhage
d) 50 % would be dead within two years
e) 60 % would respond to treatment with high dose ibuprofen
Answer: d)In patients with cystic fibrosis a FEV1 of less than 30 % would predict 50 % mortality within two years.
BOF: 46 In lung cancer which of the following features would suggest response to cytotoxic chemotherapy
a) Horner’ syndrome
b) Wasting of small muscles of hand
c) Ectopic ACTH syndrome
d) Bone metastases
e) Pleural effusion
Answer: c) In small cell lung cancer the ectopic ACTH syndrome may occur. Small cell lung cancer responds to cytotoxic chemotherapy.
BOF: 47 Which one of the following auscultatory signs is confirmatory for bronchial breathing?
a) Aegophony
b) Whispering pectoriloquy
c) Increased vocal resonance
d) Coarse crepitations
e) Fine crepitations
Answer: b) Whispering pectoriloquy is the confirmatory sign for bronchial breathing
BOF: 48 A 24-year-old male presents with sudden onset left sided pleuritic chest pain and difficulty in breathing. On examination he is distressed, tachypnoeic and has tracheal displacement to the right together with a hyper-resonant percussion note on the left side with absent breath sounds on the left. In this patient:
a) The lung will spontaneously expand within one week
b) Immediate insertion of an intercostal drainage tube is required
c) Aspiration of the pneumothorax should be undertaken in the first instance
d) Surgical pleurodesis will be required
e) Chemical pleurodesis will be required
Answer: c) Treatment of a complete pneumothorax would be initial aspiration. This is less painful, leads to a shorter duration of admission, reduces the need for leurectomy, there is no increase in recurrence rate at one year.
BOF: 49 In a man the commonest presentation of prolactinoma is with:
a) Galactorrhoea
b) Gynaecomastia
c) Impotence
d) Adiposity
e) Apathy
Answer: c) In men with prolactinoma the commonest of the features mentioned above is impotence. Approximately 8% of men presenting with sexual dysfunction have hyperprolactinaemia.
BOF: 50 An elderly female is admitted with loss of consciousness. She is hypothermic, has a bradycardia, evidence of cardiac failure, hypoventilation, hypoglycaemia and hyponatraemia. In this condition one of the treatment strategies would be:
a) Thyroxine 1000 micrograms by slow intravenous infusion every 8 hours
b) Prednisolone 60 mgs orally
c) Oral thyroxine 125 micrograms daily
d) Oral thyroxine 25 micrograms daily
e) Hydrocortisone 100 mgs iv 8 hourly
Answer: e) The patient has myxoedema coma. Hydrocortisone 100 mgs iv 8 hourly should be used to protect against the possibility of associated adrenocortical deficiency.
Title: Hypothyroidism
Aetiology: Primary Hypothyroidism
Congenital thyroid agenesis, thyroid maldescent, dyshormonogenesis
Traumatic post-thyroidectomy hypothyroidism or following radioiodine therapy
Inflammatory Hashimoto’s thyroiditis, lymphocytic thyroiditis, Riedl’s fibrosing thyroiditis
Metabolic iodine deficiency or excess
Drugs anti-thyroid drugs, lithium, amiodarone
Secondary Hypothyroidism
Panhypopituitarism
Isolated TSH deficiency almost never occurs
Clinical Features:
History:
E&M:
Tiredness
Weight gain
Cold intolerance
GIT:
Anorexia
Constipation
RAG:
Menorrhagia, oligomenorrhoea
Loss of libido
Examination:
E&M:
Increased weight
Goitre
IS:
Dry, coarse skin
Peaches and cream complexion
Dry, brittle hair
Loss of eyebrows
CVS:
Cold peripheries
Hypertension
Heart failure
Pericardial effusion
RS:
Hoarse voice
HS:
Anaemia
CNS:
Poor memory
Depression
Psychosis
Coma
Deafness
Ataxia
Carpal tunnel syndrome
Proximal myopathy
Increased ankle jerk relaxation time
Investigations:
TSH levels:
Increased
T4 level:
Decreased
Management:
Drugs: Replacement with thyroxine
BOF: 51 The commonest clinical manifestation of primary hyperparathyroidism is:
a) Renal stone disease
b) Bone disease
c) Peptic ulceration
d) Constipation
e) Polyuria
Answer: a) Renal stone disease occurs in 50 % of patients.
BOF: 52 A 50-year-old female has been referred for investigation of abnormal liver function tests. On examination she is obese with mainly truncal obesity, with a moon face and a buffalo hump shaped deposit of fat across her shoulders. Her face is plethoric and there are numerous telangiectasia. The abdomen is protuberant and there are striae. In this patient:
a) The biochemical abnormalities do not return to normal with abstinence
b) There is little relationship between the degree of liver damage and the plasma cortisol levels
c) Urinary 17 – hydroxycorticosteroid levels are suppressed
d) Plasma cortisol levels are suppressed
e) Plasma ACTH levels are elevated
Answer: b) The patient has alcoholic pseudocushings. There is little relationship between the degree of liver damage and the plasma cortisol levels
BOF: 53 A 50-year-old man presents with malaise, weight loss, diarrhoea and pain in the joints. He is pigmented, has clubbing and lymphadenopathy. He has ascites and ophthalmoplegia. Investigations show him to be anaemic. ECG shows a right bundle branch block and paracentesis abdominis reveals chylous ascites. The investigation most likely to give a diagnosis would be:
a) Lumbar puncture
b) CT head
c) Ascitic fluid cytology
d) Small bowel biopsy
e) Transoesphageal echocardiography
Answer: d) The patient has Whipple’s disease, which is diagnosed by the emonstration of multiple macrophages in the lamina propria and the presence of rod shaped bacteria both within and without the abnormal macrophages.
Title: Whipple’s Disease
Definition: A rare multisystem disease caused by Trophyrema whippelli
Aetiology: Infection by Trophyrema whippelli
Clinical Features:
Affects males > females
Usually middle aged
History:
E&M:
Weight loss
Fever
RS:
Cough
Pleuritic chest pain
GIT:
Diarrhoea
Steatorrhoea
Abdominal pain
CNS:
Insomnia, Hyperphagia, Polydypsia (Hypothalamic syndrome)
LMS:
Arthritis
Examination:
E&M: Loss of weight , Fever
IS:
Clubbing
CVS:
Endocarditis, Cardiomyopathy, Cardiac conduction defects, Coronary arteritis, Pericarditis
RS:
Pleurisy, Pulmonary infiltrates
GIT:
Chylous or serous ascites
HS:
Lymphadenopathy
CNS:
Scotoma, Ophthalmoplegia, Uveitis, Papilloedema
Meningitis
LMS:
Migratory non-deforming seronegative arthritis predominantly affecting the peripheral joints
Investigations:
FBC: anaemia
Endoscopy: Small bowel biopsy
Tissue Diagnosis: Large, foamy PAS positive macrophages in the lamina propria
Management:
Drugs:
Penicillin and streptomycin for 2 weeks followed by:
Tetracycline for 1 year
Prognosis:
Untreated it is eventually fatal
BOF: 54 A 32-year-old female who is known to have Crohn’s disease presents with increased frequency of micturition. She is demonstrated to have sterile pyuria. The lesion is likely to be:
a) Left colonic
b) Colo-vesical fistula
c) Terminal ileal
d) Recto-vesical fistula
e) Vesico-vaginal fistula
Answer: c) Crohn’s disease of the terminal ileum or left colon may involve the right ureter and result in sterile pyuria
Title: Crohn’s disease
Definition: A chronic inflammatory condition of unknown aetiology that may affect any part of the bowel from mouth to anus
Aetiology:
Unknown
Contributory factors:
Family history
Smoking
Clinical Features:
Commonly affects young adults
History:
E&M:
Loss of weight
Fever
GIT:
Mouth ulcers
Anorexia
Vomiting
Abdominal pain
Diarrhoea
Bleeding and mucous per rectum
Perianal discharge
KUB:
Dysuria and frequency due to ureteric involvement
Oxalate stones
Amyloidosis
Hydronephrosis (ureteric involvement)
Rectovesical fistulae
Examination:
E&M:
Fever
Sweats
Loss of weight
IS:
Clubbing
Erythema nodosum
CVS:
Tachycardia
GIT:
Mouth ulcers
Glossitis
Tenderness over affected bowel
Abdominal mass
Anal skin tags
Anal fissures
Perianal Fistulae
RAG:
Colovaginal, rectovaginal fistulae
HS:
Anaemia
LMS:
Enteropathic arthritis
Osteoporosis
Psoas abscess
Investigations:
FBC: Anaemia: iron deficiency, B12 deficiency, folate deficiency
Biochemistry: Hypokalaemia: diarrhoea
Albumin: decreased
ALT, alkaline phosphatase: increased
Mg, Zn, Se: may be deficient
Urine: Sterile pyuria (ureteric involvement)
Imaging:
Plain X-ray:
Intestinal obstruction
Suggestion of mass
Mucosal oedema and ulceration in colitis
CT scan: Image masses, inflammatory disease of the bowel
MRI:
Image fistulae
Small bowel imaging
Barium Studies: Small bowel studies would show ileo-caecal involvement (barium follow through or small bowel enema)
Barium enema
Nuclear Medicine:
Labeled white cell scan:
Localises inflammatory lesions
Endoscopy: Upper and lower GI endoscopy would show lesions and allow biopsies for histological conformation
Surgery:
Diagnostic laparoscopy or laparotomy
Tissue Diagnosis:
Histological conformation
Management:
Drugs:
Induction of Remission:
Steroids
Antibiotics (ciprofloxacin, metronidazole)
Infliximab
5 Amonosalicylic acid preparations
Maintenance of Remission:
5 Amonosalicylic acid preparations
Azathioprine
Methotrexate
Thalidomide
Infliximab
Surgery:
Induction of remission in localised disease
Management of complications
Lifestyle Adjustments:
Smoking:
Stop smoking
Diet:
Supplementation
Induction of remission and maintenance of remission with elemental diet, Modulen
Staffing:
Dietician regarding nutritional supplementation
Equipment:
Pumps for nutritional therapy
BOF: 55 A 30-year-old male presents with several weeks history of blood and mucous diarrhoea. He has a frequency of bowel movement of 8 times during the day and has to wake up 3 times at night to have a bowel movement. Unprepared flexible sigmoidoscopy shows an inflamed colonic mucosa. A feature that will show that this patient has disease affecting the right colon would be:
a) Serum albumin level of less than 30 g /l
b) CRP of greater than 100
c) Thumb printing on plain abdominal x-ray
d) Distended loops of small bowel
e) A tachycardia of greater than 100 per minute
Answer: d) The patient has ulcerative colitis . The presence of distended small bowel loops would suggest incompetence of the ileo-caecal valve indicating right colonic involvement.
BOF: 56 A 20-year-old male presents with bleeding oesophageal varices. On examination he has Kayser- Fleischer rings in the cornea. The inheritance of this disorder is:
a) Autosomal dominant
b) Autosomal recessive
c) X-linked recessive
d) X-linked dominant
e) Polygenic inheritance
Answer: b) This patient has Wilson’s disease, which is inherited in an autosomal recessive fashion due to a mutation on the long arm of chromosome 13
BOF: 57 A 35-year-old female presents with acute severe abdominal pain associated with tachycardia, hypotension and tachypnoea. The finding of a raised serum amylase in this patient:
a) Is diagnostic of acute pancreatitis
b) Makes ectopic pregnancy less likely
c) Makes diabetic ketoacidosis less likely
d) Could indicate a perforated duodenal ulcer
e) Makes mesenteric ischaemia less likely
Answer: d) A raised serum amylase may occur in all these conditions
BOF: 58 In primary sclerosing cholangitis:
a) There is clear female predominance
b) It is associated with Crohn’s colitis but not with ulcerative colitis
c) The liver biopsy features are diagnostic
d) Colectomy prevents the progression of the disease
e) Ursodexoycholic acid improves clinical symptoms and reduces the level of cholestatic enzyme markers
Answer: e) Ursodexoycholic acid improves clinical symptoms and reduces biochemical evidence of cholestasis but no effect on morbidity and mortality has been demonstrated.
BOF: 59 In psoriatic arthropathy:
a) There is a strong relationship between the skin changes and the severity and extent of arthritis
b) There is a close relationship between the onset of nail dystrophy and arthritis
c) Nail dystrophy is more common in patients with the spinal form of arthritis
d) Longitudinal ridging of the nails is diagnostic of psoriatic arthropathy
e) Acute anterior uveitis is common in patients with the mutilating form of psoriatic arthropathy
Answer: b)There is poor correlation between the skin changes and the arthritis although there is closer relationship between nail changes and arthritis. Nail dystrophy is common in those with distal interphalangeal joint involvement. Longitudinal ridging is not a specific associated feature of psoriatic arthropathy. Anterior uveitis is associated with sacroiliitis.
BOF: 60 In polymyalgia rheumatica:
a) The disease is common in those over 80 years of age
b) A dramatic onset is unusual
c) The onset is more common in the pelvic girdle
d) Morning stiffness is not a common feature
e) Anorexia and weight loss are features
Answer: e) Polymyalgia rheumatica is common between 60 and 70 years. It is seldom seen before 45 or after 80. The onset is often dramatic. Immobility is most severe on waking and may persist for hours. Anorexia and weight loss may be striking.
BOF: 61 An elderly lady has features of osteoporosis. She appears to have lost height due to osteoporotic collapse of the vertebrae but she does not know what her former height was. Which measurement will give an indication of her former height?
a) Length of manubrium sterni
b) Distance between the costal margin and the iliac crest
c) Diameter of the rib cage
d) Waist measurement
e) Arm span
Answer: e) In an adult the arm span and height are approximately equal. In osteoporotic collapse of the vertebrae, the arm span becomes greater than the height.
Title: Osteoporosis
Definition: A disorder characterised by loss of bone mass per unit volume with deterioration of its micro-architecture. This results in increased fragility of bone and an increased risk of fracture.
Aetiology:
The risk factors for osteoporosis are:
Internal Factors
Increasing age
Female gender
Caucasian or Asian race
Family history of osteoporosis
External Factors
Dietary factors such as a low calcium intake
Systemic Factors
Conditions affecting the:
RAG secondary amenorrhoea, primary hypogonadism, premature menopause
E&M acromegaly, hyperthyroidism, hyperparathyroidism, Cushing’s syndrome, diabetes mellitus
KUS chronic renal failure
LMS rheumatoid arthritis, prolonged immobilisation
GIT nutritional failure, inflammatory bowel disease
Drugs steroid therapy
Toxins cigarettes, alcohol
Surgery organ transplantation
Clinical Features:
In osteoporosis the only cause of symptoms is fracture. The usual sites involved are:
Spine
Colles’ fracture
Fracture neck of femur
History:
LMS:
Pain , deformity
Examination:
GIT:
Abdominal protuberance
LMS:
Loss of height, kyphosis
Dinner fork deformity in Colles’ fracture
External rotation, shortening and decreased movement of limb in fracture neck of femur
Investigations:
Imaging:
Plain X- Ray decreased bone density, reduced cortical thickness, wedge collapse of vertebrae, “codfish” vertebrae
DEXA (dual x- ray absorptiometry) provides a T score, which reflects fracture risk
Management:
Drugs:
Bisphosphonates
Hormone replacement therapy
SERM (selective oestrogen receptor modulator)
Androgens (hypogonadal men)
Calcium and vitamin D (elderly)
Lifestyle Adjustments:
Diet increased calcium and vitamin D
Exercise increase physical activity
Smoking cessation
BOF: 62 In osteoporotic collapse of the vertebra:
a) The absence of precipitating stress makes it less likely
b) The absence of severe pain will make the diagnosis less likely
c) The pain is very well localised and the absence of this symptom will exclude the diagnosis
d) The vertebrae are tender to percussion and the absence of this sign will exclude the diagnosis
e) Frequently occurs without symptoms
Answer: e) Osteoporotic collapse of the vertebrae frequently occurs without symptoms
BOF: 63 The three main sites at which osteoporotic fractures occur are:
a) Vertebrae, pelvis, femoral neck,
b) Vertebrae, femoral neck, forearm
c) Vertebrae, forearm, pelvis
d) Vertebrae, femoral neck, humerus
e) Vertebrae, forearm, ribs
Answer: b) The commonest sites of osteoporotic fracture are vertebrae, femoral neck, forearm
BOF: 64 In contrast to other forms of osteoporosis, steroid induced osteoporosis affects the:
a) Skull
b) Forearm
c) Vertebrae
d) Pelvis
e) Femoral neck
Answer: a) Osteoporosis is thought not to affect the skull except in steroid induced osteoporosis.
BOF: 65 A 45-year-old female is admitted with a subarachnoid haemorrhage. She initially, makes satisfactory progress but 5 days later her level of consciousness begins to deteriorate. The most likely cause of the deterioration is:
a) Bacterial meningitis complicating lumbar puncture
b) Cerebral abscess
c) Coning of the medulla
d) Acute hydrocephalus
e) Dural sinus thrombosis
Answer: d) Organised blood in the subarachnoid space may cause obstruction to the flow of cerebrospinal fluid and result in hydrocephalus.
BOF: 66 A 67-year-old man presents with a history of falls. He has difficulty in reading and coming down stairs. He has dysarthria, and akinesia and rigidity can be demonstrated. Power of the muscles is normal, reflexes are brisk. What physical sign will help to make the diagnosis?
a) Jaw jerk
b) Romberg’s sign
c) Tandem walking
d) Eye movements
e) Plantar response
Answer: d)
BOF: 67 A 25-year-old female has recently had a forceps delivery. She complains of pain in the groin and on examination she has weakness of adduction and internal rotation of the hip. There is sensory impairment over the medial aspect of the thigh. The affected nerve is the:
a) Femoral nerve
b) Sciatic nerve
c) Lateral cutaneous nerve of the thigh
d) Tibial nerve
e) Obturator nerve
Answer: e) The obturator nerve supplies gracilis, adductor longus and brevis, adductor magnus, obturator externus and the skin over the lateral aspect of the thigh.
BOF: 68 A 20-year-old male presents with wasting and weakness of the muscles of the pelvic girdle. There is evidence of generalised muscular hypertrophy. His maternal grandfather had a similar disorder. The mode of inheritance is
a) Autosomal dominant
b) Autosomal recessive
c) X-linked recessive
d) Polygenic inheritance
e) X-liked dominant
Answer: c) The patient has benign x-liked muscular dystrophy (Becker type)
BOF: 69 Myotonia aggravated by cold is a feature of:
a) Myotonia dystrophica
b) Myotonia congenita
c) Chondrodystrophic myotonia
d) Paramyotonia
e) Hypothyroidism
Answer: d) Myotonia appearing on exposure to cold occurs in Paramyotonia. Chondrodystrophic myotonia causes choking on cold drinks.
BOF: 70 In myasthenia gravis the tendon reflexes are:
a) Brisk
b) Absent
c) Depressed
d) Delayed
e) Pendular
Answer: a) In myasthenia gravis the tendon reflexes are characteristically brisk. If the reflexes are depressed or absent one should think of Eaton-Lambert syndrome.
BOF: 71 A 25-year-old male who is known to have ankylosing spondylitis presents with a painful, aching, photophobic red eye. Examination shows cells floating in the anterior chamber and precipitated on the back of the cornea. In this patient treatment should be commenced with:
a) High dose oral steroids
b) Broad spectrum antibiotics
c) Local steroids
d) Local steroids and dilator
e) Local steroids and a constrictor
Answer: d) The patient has anterior uveitis. Treatment should be with local steroids and a dilator to break adhesions to the lens and allow the iris to remain mobile.
BOF: 72 In diabetes mellitus eye complications that do not result in visual impairment are:
a) Cataract
b) Lipaemia retinalis
c) Rubeosis iridis
d) Retinal vein occlusion
e) Diabetic retinopathy
Answer: b) Lipaemia retinalis is seen in association with hypertriglyceridaemia and reverses with metabolic control. All other complications impair vision. Rubeosis iridis can result in glaucoma by neovascularistion of the drainage channels of the aqueous in the anterior chamber.
BOF: 73 A 27 year old female presents with abdominal pain, weight loss, diarrhoea and mouth ulcers. On clinical examination apart from mouth ulcers no abnormality is detected. Full blood count reveals normocytic normochromic anaemia, inflammatory markers are raised, and biochemical investigation reveals a raised alkaline phosphatase. Barium follow through shows terminal ileal inflammatory disease. In this patient long term remission may be maintained by the use of:
a) Low dose prednisolone
b) Mesalazine
c) Azathioprine
d) Infliximab
e) Elemental diet
Answer: c) The patient has Crohn’s disease. Induction of remission of Crohn’s disease may be achieved by the use of steroids, elemental diet, surgery or Infliximab. Mesalazine may maintain remission if induction has been achieved by surgery and if an 8-week course of metronidazole is administered. In other cases the most useful drug to maintain remission is azathioprine.
BOF: 74 An 80-year-old man has had a stroke and has a poor swallow. He keeps pulling his nasogastric tube out and is not adequately nourished. He develops diarrhoea. Stools were examined and show the presence of Clostridium difficile toxin. He has not been treated with antibiotics. In this patient the next course of action should be:
a) Arrange a colonoscopy
b) Arrange a barium enema
c) Treat with metronidazole
d) Treat with Loperamide
e) Treat with Cholestyramine
Answer: c) Infection with Clostridium difficile is usually established upon exposure to antibiotics. However, it may also occur in debilitated patients who have not been exposed to antibiotics.
BOF: 75 A 50-year-old male presents with haematemesis and melaena. He gives a history of alcohol abuse of several years duration. On examination he has bilateral parotid enlargement, spider naevi, Dupuytren’s contracture, jaundice and ascites. Whilst awaiting endoscopy the initial management of this patient should be:
a) Administration of intravenous pantoprazole
b) Administer terlipressin
c) Insert a Sengstaken tube
d) Nasogastric tube and aspiration to decompress the stomach
e) Administer sucralfate
Answer: b) The patient has clinical evidence of cirrhosis of the liver (features of portal hypertension and features of hepatocellular failure). The likely cause of the haematemesis and melaena is bleeding oesophageal varices. Until endoscopy and definitive treatment one should attempt to reduce portal venous pressure with terlipressin.
BOF: 76 The cardinal manifestation of acute hepatic failure is:
a) Jaundice
b) Prolonged prothrombin time
c) Hepatic encephalopathy
d) Ascites
e) Elevated ALT
Answer: c) Cerebral disturbance (hepatic encephalopathy) is the cardinal manifestation of acute hepatic failure.
BOF: 77 A 45-year-old female who is known to have autoimmune hepatitis, which has progressed to cirrhosis of the liver documented on liver biopsy, complains of breathlessness. The breathlessness is better when she lies down and gets worse when she is upright. Her arterial oxygen saturation is reduced on standing. The condition that this patient suffers from is an:
a) Indication for treatment with carvedilol
b) Indication for treatment digoxin
c) Indication for liver transplantation
d) Indication for home oxygen treatment
e) Indication for oral beta agonists
Answer: c) Breathlessness on standing relieved by lying down (platypnoea) together with decreased arterial oxygen saturation on standing (orhtodeoxia) are features of the hepato-pulmonary syndrome which is an indication for liver transplantation.
BOF: 78 A 26-year-old female who has been on the contraceptive pill presents with abdominal pain and distension of 5 days duration. On examination she has no stigmata of chronic liver disease. She has distended veins over the anterior abdominal wall with flow of blood in a caudal to cephalic direction .She also has ascites, an enlarged tender liver with absent hepato-jugular reflux. Her lower limbs are oedematous. In this patient the oedema of the lower limbs is due to:
a) Hypoalbuminaemia
b) Hepato-renal syndrome
a) Inferior vena cava thrombosis
b) Portal venous thrombosis
c) Lymphatic obstruction
Answer: c) Budd-Chiari syndrome is thrombosis of the hepatic veins. Lower limb oedema could occur due to associated thrombosis of the inferior vena cava.
BOF: 79 A 40-year-old male presents with a history of intermittent, but slowly progressive dysphagia for both solids and liquids. He experiences pain on swallowing and has regurgitation of food swallowed several hours earlier. He has no heartburn but has anorexia and weight loss. Ba swallow demonstrates proximal dilatation of the oesophagus and failure of relaxation of the lower oesophageal sphincter. In this patient good medium to long term relief of symptoms may be obtained by:
a) Oesophageal myotomy
b) Amyl nitrite
c) Amlodipine
d) Intrasphincteric botulinum toxin
e) Oesophageal bouginage
Answer: a) The patient has achalasia of the cardia, which is a functional obstruction at the lower oesophageal sphincter caused by a failure of relaxation. Oesophageal myotomy (Heller’s operation) and balloon dilatation give good medium to long-term results. Bouginage is not used. Drug therapy does not achieve medium to long-term relief.
BOF: 80 A 22-year-old female of Irish descent has been admitted under the care of the surgeons with a history of abdominal pain. They have concluded that the patient has non-specific abdominal pain, which they define as abdominal pain that cannot be treated by an operation. No abnormality has been detected clinically or by routine investigation. They wish to discharge the patient but would welcome your opinion. You agree to see the patient in clinic following discharge but request that they perform an investigation prior to discharge. This investigation would be:
a) B12 and folate levels
b) Urine for porphyrins
c) ANCA screen
d) Mesenteric angiogram
e) Anti gliaden and anti endomysial antibodies
Answer: e) Coeliac disease presents with abdominal pain and a coeliac screen would be a good screening test for this condition.
BOF: 81 A 55-year-old Caucasian male presents with a 2-year history of arthritis, fever, recurrent cough and chest pain. He has been feeling generally unwell. Recently he has developed diarrhoea (steatorrhoea), abdominal pain and weight loss.On examination he is pigmented, there is finger clubbing and lymphadenopathy. On auscultation of the heart a pan-systolic murmur is heard.Which of the following investigations would confirm your clinical diagnosis?
a) ECHO
b) Blood cultures
c) Lymph node biopsy
d) Small bowel biopsy
e) Mesenteric angiogram
Answer: d)The patient has Whipple’s disease, which may be confirmed by small bowel biopsy. Small bowel biopsy will show large, foamy PAS positive macrophages in the lamina propria.
BOF: 82 A 35-year-old male intravenous drug abuser presents to his GP with a complaint of severe fatigue and a blistering eruption on the sun exposed areas of his skin. He also abuses alcohol consuming between 30-40 units a week. The GP carries out blood test and refers him for investigation of abnormal liver function tests.
In this patient:
a) Combination therapy will induce a response in 90% of patients
b) Development of cirrhosis does not preclude a good response to treatment
c) If the patient develops cirrhosis he has an 80-90% chance of developing hepatocellular carcinoma.
d) Without treatment end stage liver failure will develop in 2-3 years
e) In patients without cirrhosis, combination therapy induces a response in 45% of patients
Answer: e) The patient has hepatitis C with associated porphyria cutanea tarda. Significant liver disease develops in 20-30 % of patients who have necro-inflammatory disease. The process takes 20-30 years. Development of cirrhosis results in a poor response to combination therapy (Interferon and ribavarin) although the newer PEGylated interferons yield a better virological response. Once cirrhosis is established the incidence of hepatocellular cancer is 1.5-2 % per year.
BOF: 83 A 50-year-old male has been seen by his GP who has made a diagnosis of diabetes mellitus. On routine investigation he has been noted to have abnormal liver function tests. The GP refers him to the clinic querying non-alcoholic fatty liver disease. On examination he is pigmented, there is loss of body hair, gynaecomastia, testicular atrophy, and an arthropathy of his knee joints.In this patient treatment of the underlying condition will:
a) Increase the severity of the diabetes mellitus
b) Increase the size of the liver
c) Reverse any changes of cirrhosis
d) Only results in decrease in malaise and decreases liver size
e) Improves 5- year survival rate
Answer: e) The patient has haemochromatosis. Venesection is the best method of depleting body iron stores. It decreases the severity of diabetes mellitus and results in a general improvement in malaise and decreases liver size. The changes of cirrhosis are not reversible. Five-year survival has improved from 4.4 years in 1935 to 89% in 1969.
BOF: 84 A 40-year-old female presents with hepatitis. She also has arthralgia and autoimmune thyroid disease. Investigations reveal high serum transaminases, increase in total globulin and smooth muscle antibodies are positive.Where treatment of this condition is concerned:
a) Steroids are contraindicated as they increase the risk of osteoporosis
b) Steroids reduce the enzyme levels and decrease jaundice but are of no long term benefit
c) Steroids improve survival rate, but do not prevent development of cirrhosis
d) Steroids should be used continuously for 4 years
e) Azathioprine is as effective as steroids and can be used instead of steroids in older females
Answer:c) The patient has autoimmune hepatitis. In this condition response to steroids is excellent and improves five-year survival but does not prevent development of cirrhosis. Azathioprine is an useful adjunct to steroids and allows a lower dose of steroids to be used and thus reduces the risk of osteoporosis. If the disease is inactive for 2 years steroids may be cautiously withdrawn. Relapse is common (60-80 %) and necessitates reintroduction of steroids.
BOF: 85 A 50-year-old female presents with weakness of her left upper limb, which developed overnight. She says she fell asleep on a chair. On examination there is weakness of extension of her left elbow, a wrist drop and absent sensation over the first interosseus space of her left hand on the dorsal aspect. The lesion is in the:
a) Ulnar nerve at the elbow
b) Musculocutaneous nerve
c) Radial nerve in the spiral groove
d) Radial nerve in the axilla
e) Upper brachial plexus
Answer: d) The weakness of extension of the elbow indicates weakness of the triceps hence the lesion should be in the axilla. Lesions of the radial nerve in the spiral groove spare the triceps.
BOF: 86 A 32-year-old female who has had surgery on her cervical spine following a car accident presents with sudden onset of left-sided weakness. The weakness developed when she looked up whilst bending to pick up an object. On examination she has a hemiplegia affecting the left face arm and leg. She also has unilateral internuclear ophthalmoplegia with failure of adduction to the left and nystagmus to the left. She also has early papilloedema. In this patient MRI shows:
a) Right mid brain infarct
b) Left mid brain infarct
c) Right pontine infarct
d) Left pontine infarct
e) Lateral medullary syndrome
Answer: a) The patient has unilateral internuclear ophthalmoplegia. The side of the lesion is the side of the failure of adduction not the side of the nystagmus. This localises the lesion to the right medial longitudinal fasiculus. To cause weakness of face arm and leg the lesion must be above the pons.
BOF: 87 A 32-year-old female who has had surgery on her cervical spine following a car accident presents with sudden onset of left-sided weakness. The weakness developed when she looked up whilst bending to pick up an object. On examination she has a hemiplegia affecting the left face arm and leg. She also has unilateral internuclear ophthalmoplegia with failure of adduction to the left and nystagmus to the left. She also has early papilloedema. In this patient the papilloedema is due to:
a) Obstruction of the foramen of Magendie
b) Obstruction of the foramen of Luschka
c) Obstruction of the aqueduct of Sylvius
d) Obstruction of the foramen of Monro
e) Obstruction of the foramen of Morgagni
Answer: c) The aqueduct of the midbrain (the aqueduct of Sylvius) runs in the tegmentum of the midbrain and joins the third and fourth ventricles. Oedema around the midbrain infarct would have compressed the aqueduct and resulted in obstructive hydrocephalus and papilloedema.
BOF 88 A 57-year-old female who is known to have rheumatoid arthritis has been on penicillamine for treatment of her condition. She presents with oedema, proteinuria, hypoalbuminaemia and her serum cholesterol levels are elevated. In this patient renal biopsy:
a) Is indicated as she may have developed a vasculitis
b) Is indicated to decide if she needs steroids and immunosuppression
c) Should be performed in order to demonstrate minimal change nephropathy as this will respond to steroids
d) Is indicated to look for amyloidosis
e) Is not indicated
Answer: e) The patient has nephrotic syndrome. In patients on drugs such as penicillamine it is best to stop the drugs and assess response first, rather than proceed to renal biopsy. In nephrotic syndrome, renal biopsy is not indicated in: Young children, especially males, with a highly selective protein leak, no hypertension, no red cells or red cell casts in the urine Long standing insulin dependent diabetes mellitus with associated retinopathy or neuropathy as here the most likely diagnosis is diabetic nephropathy Patients on drugs, which should be stopped first
Title: Nephrotic Syndrome
Definition: The nephrotic syndrome consists of heavy proteinuria, hypoalbuminaemia and oedema. Hypercholesterolaemia is almost always present.
Aetiology:
Glomerulonephritis
Systemic vasculitides especially systemic lupus erythematosus
Diabetic nephropathy
Amyloidosis
Drugs: penicillamine, captopril, gold
Allergies
Clinical Features:
History:
KUS:
Swelling of the body
Frothy urine
Examination:
CVS
Venous thrombosis occurs due to:
Loss of factors such as antithrombin
Increased production of fibrinogen
KUS:
Oedema
Investigations:
Urine:
Proteinuria
24-hour urinary protein more than 3-5 gram daily
Selective protein clearance
Selective: minimal change nephropathy, early diabetes, amyloid
Unselective leak: in severe glomerulonephritis
Blood:
Serum albumin less than 30 g/dl
Serum electrophoresis: reduced serum albumin with an increase in alpha and beta globulin
Tissue Diagnosis:
Renal biopsy is indicated to see if the cause is a steroid sensitive lesion
Management:
Drugs:
Diuretics
Steroids
Cyclophosphamide
Cyclosporin
Vaccines:
Pneumococcal vaccine should be given, as sepsis is common in the nephrotic syndrome
Lifestyle Adjustments:
Diet high protein diet
BOF: 89 A 60-year-old male with uncomplicated stable alcoholic cirrhosis presents with severe breathlessness on exertion. On examination he was found to be anaemic and jaundiced. He has splenomegaly. His Hb is 8 gm/dl with normal MCV. WBC and platelet count are normal. There is no evidence of blood loss. Iron studies and red cell folate assay are normal. What is the most likely explanation for his anaemia?
a) Burr cell anaemia
b) Paroxysmal cold haemoglobinuria
c) Autoimmune haemolytic anaemia
d) Spur cell anaemia
e) Hypersplenism
Answer: d) Spur cell anaemia should be suspected when the anaemia is more severe than is observed in otherwise uncomplicated cirrhosis. Splenomegaly is always present. The RBC are irregularly shaped with multiple spicules. The surface membrane of a spur cell contains 50 – 70% excess cholesterol. Spur cells are distinguished from regularly spaced crenated RBC (Burr cells), which are present in some patients with uraemia. It is not hypersplenism because his white cells and platelets are normal.
BOF: 90 Which of the following conditions is most likely to be associated with Paroxysmal Cold Haemoglobinuria
a) Mycoplasma infection
b) Lymphoma
c) Systemic lupus erythematosus
d) Tertiary syphilis
e) Chronic lymphocytic leukaemia
Answer: d) This is a rare disorder now. It was more frequent when tertiary syphilis was prevalent. Now most cases are either secondary to a viral infection (measles and mumps in children) or are autoimmune. Paroxysmal Cold Haemoglobinuria results from the formation of the Donath-Landsteiner antibody, an IgG antibody that is directed against the P antigen. This can induce complement-mediated lysis. Attacks are precipitated by exposure to cold and are associated with haemoglobinemia and haemoglobinuria.
BOF: 91 A 40-year-old male was admitted with sudden onset headache and generalised tonic-clonic convulsion. MRI scan and subsequent MRI venography revealed sagittal sinus thrombosis. He recently recovered from an episode of aplastic anaemia. Investigation reveals anaemia with reticulocytosis. What is the most likely diagnosis?
a) Homocystinuria
b) Thrombotic thrombocytopaenic purpura
c) Paroxysmal Cold Haemoglobinuria
d) Paroxysmal Nocturnal Haemoglobinuria
e) Thalassaemia
Answer: d) Paroxysmal Nocturnal Haemoglobinuria (PNH) is an intracorpuscular defect acquired at the stem cell level. Three common manifestations are haemolytic anaemia, venous thrombosis and deficient haematopoiesis. Granulocytopaenia and thrombocytopaenia are common and reflect deficient haematopoiesis. Clinical haemoglobinuria is intermittent in most patients and never occurs in some, but haemosiderinuria is usually present. Venous thrombosis is a common complication of patients of European origin. Thrombosis can occur in cerebral venous sinuses and is a common cause of death in a patient with PNH.
Title: Paroxysmal Nocturnal Haemoglobinuria
Definition: A rare acquired red cell defect in which a clone of red cells is particularly sensitive to destruction by activated complement
Clinical Features:
History:
HS:
Breathlessness
GIT:
Recurrent abdominal pains
KUS:
Voiding of dark urine in the night or in the morning on waking
Examination:
CVS:
Venous thrombosis, which may be unusual such as Budd-Chiari syndrome, mesenteric vein thrombosis, cerebral vein thrombosis
Investigations:
Blood:
Anaemia
Thrombocytopaenia and neutropaenia may also occur
Flow Cytometric Analysis with anti CD 55 and anti CD 59. This has replaced Ham’s test
Tissue Diagnosis:
Bone marrow may be hypoplastic
Management:
Support:
Blood transfusion
Drugs:
Long term anticoagulation
Immunosuppression with antilymphocyte globulin or cyclosporin for bone marrow failure
Bone marrow transplantation
Prognosis:
PNH may transform into aplastic anaemia or acute leukaemia
BOF: 92 Thrombocytosis does not occur in:
a) Essential Thrombocytosis
b) Systemic Lupus Erythematosus
c) Inflammatory Bowel Disease
d) Acute Myeloid Leukaemia
e) Hyposplenism
Answer: d) Acute Myeloid Leukaemia (AML) causes thrombocytopaenia. Chronic Myeloid Leukaemia can cause thrombocytosis. Idiopathic sideroblastic anaemia and Myelodysplasia can cause thrombocytosis. Essential thrombocytosis is a clonal disorder of unknown aetiology and manifests clinically by the overproduction of platelets. It is often identified incidentally. Patients with Essential Thrombocytosis do have haemorrhagic and thrombotic tendencies
BOF: 93 Which of the following statements is not true about Waldenstrom’s Macroglobulinaemia?
a) Hypercalcaemia is common
b) Renal disease is not common
c) Peripheral neuropathy is not uncommon
d) Hepatosplenomegaly can occur
e) Lymphadenopathy is not uncommon
Answer: a) Waldenstrom’s Macroglobulinaemia is a malignancy of lymphoplasmacytoid cells. The disease is associated with lymphadenopathy, epatosplenomegaly and the hyperviscosity syndrome. The disease involves the bone marrow, but doesn’t ause lytic bone lesions or hypercalcaemia. IgM paraprotein has got very little excretion hrough urine because of its size. Therefore renal disease is not
common.
BOF: 94 Alopecia is not a feature of:
a) Secondary Syphilis
b) Hypothyroidism
c) Hypopituitarism
d) Hyperthyroidism
e) Hypoparathyroidism
Answer: e) Other systemic diseases that cause alopecia are lupus erythematosus, deficiencies of protein/iron/zinc/biotin, HIV infection
BOF: 95 Hyperpigmentation is not a manifestation of:
a) Addison’s disease
b) Vitamin B12 deficiency
c) Pellagra
d) Whipple’s disease
e) Systemic Lupus Erythematosus
Answer: e) Scleroderma can cause hyperpigmentation. Other conditions causing pigmentation are Nelson syndrome, Porphyria Cutanea Tarda, Haemochromatosis, Folate deficiency, Malabsorption, Biliary Cirrhosis, Eosinophilia-myalgia syndrome and POEMS syndrome.
BOF: 96 The following statements about Dermatitis Herpetiformis is false:
a) Papulovesicular lesions over the extensor surfaces are common
b) The rash is non-pruritic
c) Almost all patients have associated sub-clinical gluten-sensitive enteropathy
d) IgA is deposited in the skin
e) Increased incidence of thyroid abnormalities are found
Answer: b) Dermatitis Herpetiformis is intensely pruritic. Most patients with dermatitis herpetiformis do not report overt gastrointestinal symptoms or laboratory evidence of malabsorption. They also have increased incidence of thyroid abnormalities, achlorhydria, atrophic gastritis and antigastric parietal cell antibody. Dapsone is the initial treatment with institution of a gluten free diet.
BOF: 97 A 55-year-old male presents with acute bilateral visual loss. Both the optic discs are swollen and a central scotoma is detected. In further investigation of the cause of this condition the following blood levels are not required:
a) Ethylene glycol
b) Thiamine
c) Vit.B12
d) Folate
e) Vitamin A
Answer:e) The diagnosis is Toxic Optic Neuropathy. This can happen from exposure to ethambutol, methyl alcohol, ethylene glycol or carbon monoxide. Deficiency states induced either by starvation, malabsorption or alcoholism can lead to insidious visual loss. Thiamine, vitamin B12 and folate level should be checked in any patient with unexplained bilateral central scotoma and optic pallor
BOF: 98 Which of the following is not a clinical sequel of rhabdomyolysis:
a) Hypovolaemia
b) Metabolic alkalosis
c) Hyperkalaemia
d) Acute renal failure
e) Disseminated intravascular coagulation
Answer: b)Metabolic acidosis occurs in rhabdomyolysis due to release of cellular phosphate and sulphate.
Cardiovascular System ::
a) Mitral Stenosis
b) Mitral regurgitation
c) Mitral valve prolapse
d) Mitral valve replacement
e) Aortic stenosis
f) Aortic sclerosis
g) Aortic regurgitation
h) Aortic valve replacement
i) Pulmonary stenosis
j) Pulmonary regurgitation
k) Tricuspid stenosis
l) Tricuspid regurgitation
m) Infective endocarditis
n) Atrial septal defect
o) Ventricular septal defect
p) Patent ductus arteriosus
q) Coarctation of the aorta
r) Eisenmenger syndrome
s) Fallot’s tetralogy
t) Right ventricular failure
u) Left ventricular failure
v) Congestive cardiac failure
Patient 1 An elderly female /Height 1.56 m /Weight 54 kg /Comfortable in bed / Dowager’s hump /No malar flush /No clubbing /No splinter haemorrhages /Pulse 60 beats per minute, regular rhythm, small volume, slow rising, no collapse, no Bisferiens pulse, no radio-radial or radio-femoral delay
JVP not raised
Carotid pulse slow rising
Apex beat 5 LICS anterior axillary line, heaving, no thrill
Heart Sounds S1 normal S2 soft
Harsh ejection systolic murmur best heard in the aortic area radiating to the neck
Marked kyphosis
No sacral oedema
Lung bases clear
Answer: e) Aortic Stenosis ….The slow rising pulse suggests aortic outflow obstruction. The heaving apex suggests that the ventricle is contracting against resistance and is therefore stenotic rather than sclerotic.The displacement of the apex beat would suggest left ventricular dilatation and hence aortic regurgitation but this is not a true displacement of the left ventricle but is an apparent displacement as the patient has osteoporosis (marked kyphosis, dowager’s hump) and contraction of the ribcage.
Patient 2 The patient is a 75-year-old male who is 1.54 m tall and his weight is 55 kg. He appears comfortable at rest.
No pallor, no cyanosis.
No clubbing, no splinter haemorrhages. Peripheries are warm. Pulse rate 80 beats per minute, large volume, normal character (no collapse, no Bisferiens) no radio-radial or radio-femoral delay. Brachial artery is normal and there is no brachio-radial delay.
JVP not elevated carotid pulses are normal. Trachea is in the midline.
No deformity of the chest, no praecordial deformity or pulsation. Apex beat 5 LICS, MCL, normal character, no thrills. Heart sounds normal. There is a systolic murmur best heard in the aortic area although it is also heard well at the apex.
On asking the patient to sit up and lean forward a thrill is palpable at the 2 RICS just lateral to the sternum. A soft blowing early diastolic murmur is now heard at the left sternal edge.
No abnormality of the spine, no sacral oedema, lungs clear.
On auscultation of the femoral arteries no femoral thud or pistol shot is heard but a systolic bruit is heard when the artery is lightly compressed with the bell of the stethoscope.
Answer: e) Aortic Stenosis g) Aortic Regurgitation
Patient 3 The patient is a 43-year-old Caucasian male. He appears to be dyspnoeic and is propped up in bed. He is 1.77 metres tall and his weight is 72 kgs. His arm span measures1.82 metres. The lower segment of his body measures 91.44 cms. His skin appears pigmented.
His face is narrow and long and on examination of his mouth he has a high arched palate.
His hands appear long and his fingers are long and narrow. There is no clubbing, no splinter haemorrhages. There is no nail bed pulsation.
His pulse rate is 100 beats per minute, the rhythm is regular. The volume of the pulse is large and on raising the patient’ arms a collapsing pulse is felt. There is no Bisferiens pulse. There is no radio- radial or radio-femoral delay.
There is a sinuous pulsation in the neck which can be obliterated by pressure at the root of the neck and which increases when pressure is applied over the liver. There is no other visible pulsation. The trachea is in the midline.
His respiratory rate is 24 breaths per minute.
There is a depression at the lower end of the sternum. No praecordial pulsations are seen. The apex beat is at the sixth left intercostal space in the anterior axillary line. Normal character. No thrills are palpable.
On auscultation a third heart sound is audible at the apex of the heart. There is a pan-systolic murmur at the left sternal edge and this murmur does not radiate.
On asking the patient to sit up, lean forward and hold the breath in expiration, a short ejection systolic murmur and a short early diastolic murmur are heard at the left sternal edge.
The lungs are clear.
On auscultation over the femoral arteries a thud may be heard in systole and when the artery is lightly compressed with the bell of the stethoscope a systolic and diastolic bruit are heard.
The patient has bilateral ankle oedema.
Answer: g) Aortic Regurgitation l) Tricuspid regurgitation v) Congestive cardiac failure The patient also has features of Marfan's syndrome
Patient 4 A 78-year-old male. He is comfortable at rest. He is 1.77 m tall and weighs 78 kgs. He has no icterus and there is no pallor.
He has no clubbing there are no splinter haemorrhages.
His pulse rate is 80 beats per minute, regular rhythm, the pulse volume is large and a collapse can be detected. No bisferiens pulse. No brachio-radial delay. No radio-radial or radio-femoral delay.
The JVP is not elevated and the carotid pulses are normal. The trachea is in the midline.
No respiratory distress, no deformity of the chest. The apex beat is palpable in the sixth left intercostal space at the anterior axillary line. It is thrusting in nature. The first heart sound is not palpable. No thrills are palpable. Heart sounds are in dual rhythm. The first heart sound is of normal intensity and so is the second. There is an ejection systolic murmur at the aortic area and the left sternal edge and a blowing early diastolic murmur at the left sternal edge, best heard with the patient leaning forward and holding his breath in expiation. The ejection systolic murmur does not radiate to the neck. A rumbling mid-diastolic murmur is audible just medial to the apex of the heart.
The lungs are clear.
On auscultation over the femoral arteries a systolic bruit is audible on light compression with the stethoscope. No diastolic bruit, no pistol shot, no femoral thud.
Answer: g) Aortic Regurgitation …The patient does not have mixed aortic valve disease because there is no bisferiens pulse, no thrill, no radiation of the murmur to the patient’s neck. The mid-diastolic murmur is an Austin-Flint murmur. It is not due to mitral stenosis because the patient is in sinus rhythm, no parasternal heave, the first heart sound is not palpable and not loud, no opening snap, no pre-systolic accentuation .
Abdominal Examination
a) Hepatomegaly
b) Splenomegaly
c) Portal hypertension
d) Acute Hepatocellular failure
e) Chronic hepatocellular failure
f) Cirrhosis of the liver
g) Polycystic kidneys
h) Transplanted kidney
i) Renal carcinoma
j) Crohn’s mass
k) Carcinoma colon
l) Aortic aneurysm
m) Para-aortic lymphadenopathy
n) Ascites
o) Renal bruit
p) Hepatic bruit
q) Venous hum
r) Alcohol abuse
Patient 1 The patient is a 40-year-old Caucasian male. He is not well dressed. His spectacles are broken and held together with sticking plaster. His height is 1.77 m and his weight is 85 kg. His skin looks deeply pigmented.
His sclera is icteric. His hair is overgrown and not well groomed. There are several small telangiectasiae over his malar region. He has a full beard and moustache. There is no parotid enlargement.
He does not have leuconychia; there is no palmar erythema. He does have Dupuytren’s contracture. The peripheral circulation appears adequate; pulse rate 90 beats per minute regular, no collapse. No tremor or flapping tremor.
His JVP is not raised.
No spider naevi. He has hair on his chest. No gynaecomastia.
The abdomen is distended but the distension appears asymmetrical with the right hypochondrium being unduly prominent. No distended abdominal veins. The abdominal wall moves normally with respiration and there is no visible peristalsis.
There is a lump in the right hypochondrium. It has a well-defined edge, smooth surface, non-tender. It is not possible to get above the lump. There are no other masses.
Percussion note over the lump is dull and the dullness continues to the 5th right intercostal space mid clavicular line. No flank dullness, no dullness in the suprapubic region.
Normal bowel sounds no bruits.
Answer: a) Hepatomegaly d) Acute Hepatocellular failure r) Alcohol abuse
The unkempt appearance, broken spectacles and Dupuytren’s contracture would suggest the aetiology is alcohol abuse.
Jaundice suggests acute hepatocellular failure.
The lump in the right hypochondrium is an enlarged liver.
Does the patient have cirrhosis of the liver?
No, there is no clinical evidence of chronic hepatocellular failure nor is there evidence of portal hypertension.
BOF 99 Which one of the following tumours, in advanced stages, is not poorly responsive to chemotherapy?
a) Pancreatic carcinoma
b) Hypernephroma
c) Gall Bladder carcinoma
d) Ovarian carcinoma
e) Non-small cell lung carcinoma
Answer d) Other cancers that are poorly responsive to chemotherapy are thyroid carcinoma, carcinoma of vulva, colorectal carcinoma, prostate carcinoma, melanoma and hepatocellular carcinoma
BOF: 99 A 55-year-old male presents with acute bilateral visual loss. Both the optic discs are swollen and a central scotoma is detected. In further investigation of the cause of this condition the following blood levels are not required:
a) Ethylene glycol
b) Thiamine
c) Vit.B12
d) Folate
e) Vitamin A
Answer: e) The diagnosis is Toxic Optic Neuropathy. This can happen from exposure to ethambutol, methyl alcohol, ethylene glycol or carbon monoxide. Deficiency states induced either by starvation, malabsorption or alcoholism can lead to insidious visual loss. Thiamine, vitamin B12 and folate level should be checked in any patient with unexplained bilateral central scotoma and optic pallor
Respiratory System
a) Chronic bronchitis
b) Emphysema
c) Fibrosing alveolitis
d) Bronchiectasis
e) Consolidation
f) Collapse
g) Cavitation
h) Pulmonary fibrosis
i) Lobectomy
j) Pneumonectcomy
k) Lung abscess
l) Bronchial carcinoma
m) Pleural effusion
n) Empyema
o) Pleural thickening
p) Pneumothorax
q) Superior vena cava obstruction
r) Cor pulmonale
s) Horner’s syndrome
t) T1 lesion
u) Pancoast’s syndrome
Patient 1 A 70-year-old male who looks unwell and distressed. His height is 1.65 m and his weight is 60 kg.
He has flaring of his alae nasi but there is no polycythaemia or cyanosis.
He has clubbing of his fingers and tar staining of his fingers. There is no hypertrophic pulmonary osteoarthropathy.
His JVP is not elevated; the trachea is in the midline.
The respiratory rate is 26 per minute. The apex beat is difficult to palpate. Respiratory movements are diminished at the left base. Vocal fremitus is reduced at the left base. Percussion note is dull at the left base (stony dullness). Breath sounds are diminished at the left base and there is a patch of bronchial breathing (confirmed by whispering pectoriloquy) around the inferior angle of the scapula. Vocal resonance is diminished at the left base and around the level of the inferior angle of the scapula aegophony can be heard (just below the area at which bronchial breathing can be heard).
Answer: e) Consolidation / f) Collapse
m) Pleural effusion
l) Bronchial Carcinoma
The patient has a collapse/consolidation with overlying pleural effusion in the left lung. It is likely to be a bronchial carcinoma in view of the clubbing, tar staining and the fact that the trachea is not displaced despite the effusion.
Patient 2 The patient is a 65-year-old lady. Her height is 1.54 m and her weight is 50 kg. She appears breathless on minimal exertion. There is an oxygen mask lying on the cupboard by her bedside.
Her alae nasi flare with respiration, there is no polycythaemia or cyanosis.
Her nails are not clubbed. No peripheral cyanosis is observed. Her hands are warm to touch, the radial pulse rate is 90 beats per minute and regular and there is no tremor or flapping tremor.
Her JVP is elevated 5 cms above the manubriosternal angle, both a and v waves can be seen and there is no dominant wave. The trachea is in the midline.
Her respiratory rate is 28 per minute. The apex beat is at the 5 LICS lateral to the MCL. Respiratory movements are equal on the two sides. Vocal fremitus is equal on the two sides. Percussion note is normal and cardiac and liver dullness are not decreased.
Breath sounds are vesicular and equal on the two sides, vocal resonance is normal and equal on the two sides. Fine late inspiratory crepitations are heard at the lung bases.
The second heart sound is loud and split, the split varying normally with respiration.
Answer:
c) Cryptogenic Fibrosing Alveolitis
r) Cor pulmonale
A thin elderly lady who is breathless at rest and has fine late inspiratory crepitations at the lung bases is most likely to be suffering from fibrosing alveolitis. The loud, split P2
suggests pulmonary hypertension and the elevated JVP in association with elevation of
both a and v waves suggests right heart failure
The patient’s chest x-ray showed an enlarged boot-shaped heart with dilated pulmonary arteries.
Patient 3 The patient is a 75-year-old male. His height is 1.67 m weight is 68 kg.
He appears breathless on minimal exertion and there is an oxygen mask by his side.
His left eyelid appears drooping and his left pupil is constricted. There is no polycythaemia or central cyanosis.
His fingers are clubbed. There is wasting of all the small muscles of his left hand. His pulse rate is 90 beats per minute and regular. There is no tremor nor is there a flapping tremor.
His JVP is not raised. The trachea is deviated to the left. He has bilateral cervical lymphadenopathy and the lymph nodes in the supraclavicular region are firm and matted.
The respiratory rate is 26 per minute. The apex beat is in the 6 LICS anterior axillary line. Respiratory movements are decreased at the right base. Vocal fremitus is decreased at the right base. Percussion note is stony dull at the right base. Breath sounds are diminished at the right base and vocal resonance is decreased at the right base.
Answer:
m) Pleural effusion
l) Bronchial Carcinoma
s) Horner’s syndrome
t) T1 lesion
The clubbing and right-sided pleural effusion suggests a bronchial malignancy with effusion. The Horner’s syndrome and T 1 lesion are due to cervical lymphadenopathy rather than a left apical bronchial cancer.
Eyes
a) Glaucoma
b) Optic atrophy
c) Papilloedema
d) Papillitis
e) Central retinal vein thrombosis
f) Central retinal artery occlusion
g) Branch retinal artery occlusion
h) Angioid streaks
i) Myelinated nerve fibres
j) Diabetic retinopathy (Background)
k) Diabetic retinopathy (preproliferative)
l) Diabetic retinopathy (proliferative)
m) Hypertensive retinopathy (grade 1)
n) Hypertensive retinopathy (grade 2)
o) Hypertensive retinopathy (grade 3)
p) Hypertensive retinopathy (grade 4)
q) Acute choroiditis
r) Chronic choroiditis
s) Drusen
t) Age related macular degeneration
u) Retinitis pigmentosa
v) Retinal detachment
w) Laser burns
x) Vitreous haemorrhage
y) Asteroid hyalosis
z) Synchysis scintillans
aa) Subhyaloid haemorrhage
Patient 1 A 45-year-old female. Pale disc with decreased blood vessels crossing the disc. Black pigment (similar to bone corpuscles) seen scattered throughout the retina.
Answer:
b) Optic atrophy
u) Retinitis pigmentosa
Retinitis pigmentosa causes consecutive optic atrophy.
Patient 2 A 70-year-old female. She has drooping of her right eyelid. Her right iris is blue in colour and the left iris is brown. The right pupil is smaller than the left.
Answer: b) Horner’s syndrome ..She has heterochromia iridis. This is congenital Horner’s syndrome
Patient 3 A 70-year-old male. On examination of the fundus the disc appears pale. On more detailed inspection the optic cup is deep (like a well) and the blood vessels appear to climb out of this deepened cup. The rest of the fundus is normal.
Answer: a) Glaucoma
Skin
a) Ehlers-Danlos syndrome
b) Pseudoxanthoma elasticum
c) Neurofibromatosis
d) Systemic sclerosis
e) Peutz-Jeghers syndrome
f) Osler-Rendu-Weber syndrome
g) Sturge-Weber syndrome
h) Neurofibromatosis
i) Tuberose sclerosis
j) Systemic sclerosis
k) Psoriasis
l) Lichen planus
m) Lupus pernio
n) Lupus vulgaris
o) Erythema nodosum
p) Dermatitis herpetiformis
q) Necrobiosis lipoidica diabeticorum
r) Pretibial myxoedema
s) Acanthosis nigricans
Patient 1 The patient is a 50-year-old female. Her height is 1.6 m weight 58 kg. Her nose is beak like and there are multiple telangiectasiae over her face. Her mouth appears small and rounded. Her hands look small and the fingers are thin and tapered. The skin over the fingers is taut.
Answer: d) Systemic sclerosis
Patient 2 The patient is a 60-year-old male. He is 1.65 metres tall and his weight is 65 kg. There are multiple fleshy papules and nodules distributed all over his body. In his iris there are a few deeply pigmented lesions. On his trunk there are several pigmented macules and in his axilla there are several smaller pigmented macules.
Answer: h) Neurofibromatosis
Patient 3 The patient is a 60-year-old male. He has multiple red plaques with silvery scales on his scalp, over his elbows and over the lower limbs. On examination of his hands there is a flexion deformity of the terminal interphalangeal joints (mallet finger) of his right and left index and fourth fingers.
Answer: k) Psoriasis
Endocrine
a) Acromegaly
b) Nelson’s syndrome
c) Hypopituitarism
d) Hypothyroidism
e) Hyperthyroidism
f) Goitre
g) Pseudohypoparathyroidism
h) Cushing’s syndrome
i) Addison’s disease
Patient 1 The patient is a 45-year-old female. She is 1.6 m tall and her weight is 85 kg. Her face looks plump but the skin is not oily and she does not have acne.Her hands look normal. The circumference of the upper limbs appears disproportionate to the torso. Over her forearms and upper arms there are multiple erythematous papules and pustules. There is a pad of fat just below her neck posteriorly. Her abdomen shows a midline surgical scar and there is a large fatty apron. No striae. Her lower limbs appear narrow in comparison to her torso.
Answer: h) Cushing's Syndrome
Patient 2 The patient is a 75-year-old Caucasian male. He is 1.67 m tall and his weight is 66 kg. His skin is pigmented. There is pigmentation of his buccal mucosa and the skin creases of his palms are pigmented. His nipples and areola are deeply pigmented. The abdomen does not show any scars and on turning the patient no scars are seen at the back.
Answer: i) Addison's Disease
Patient 3 The patient is a young female. She is quite short (4 foot 11 inches or 1.49 m). She is plump and her face appears rounded (chubby). On examination of her hands her 4th and 5th fingers are short and when she makes a fist it appears that the 4th and 5th metacarpals are short.
Answer: g) Pseudohypoparathyroidism
Patient 4 The patient is a middle aged female. She is about 1.62 m tall and is overweight. She is seated comfortably in a chair. On examination of her eyes there is proptosis, lid retraction and exophthalmos. The conjunctiva is oedematous. On testing eye movements one may detect lid lag and on extremes of eye movement the patient complains of double vision. On examination of her hands there is no tremor pulse rate 80 beats per minute and regular.On examination of the neck there is no goitre.
Answer: f) Thyroid (Grave’s) ophthalmopathy She is euthyroid
Locomotor System
a) Rheumatoid arthritis
b) Psoriatic arthropathy
c) Systemic lupus erythematosus
d) Enteropathic arthritis
e) Ankylosing spondylitis
f) Gout
g) Osteoarthritis
h) Paget’s disease
i) Polymyositis
Patient 1 The patient is a 35-year-old male. He is 1.72m tall and his weight is 75 kg. He appears stooped and when asked to back up against a wall his occiput does not reach the wall. There is loss of the lumbar lordosis and he has a kyphosis. His abdomen is protuberant. All spinal movements are decreased.
Answer: e) Ankylosing Spondylitis
Title: Ankylosing Spondylitis
Definition: Ankylosing spondylitis is a systemic rheumatic disorder that is characterised by inflammation of the axial skeleton and the large peripheral joints.
Aetiology:
Related to the incidence of HLA-B 27
Clinical Features:
History:
More frequent in men. Milder disease in women.
Age of presentation 20- 40 years.
E&M:
Low-grade fever
Weight loss
GIT:
Anorexia
LMS:
Pain and stiffness in the back
Worse in the morning, relieved by activity
Examination:
E&M:
Weight loss
CVS:
Aortic incompetence
Angina
Pericarditis
Conduction defects
RS:
Apical fibrosis and cavitation
CNS:
Anterior uveitis
Radiculitis
Sciatica
Vertebral fracture, subluxation
Cauda equina syndrome
LMS:
Loss of lumbar lordosis
Kyphosis
Decreased spinal movements
Costochondritis
Peripheral joint involvement asymmetrical large joints
Investigations:
Blood:
ESR, CRP mildly elevated
HLA-B27 positive supporting evidence
X-Ray:
Sacroiliitis
Squaring of vertebrae, demineralisation, ligamentous calcification, bamboo spine ultimately
Management:
Drugs:
NSAIDS for pain
Sulphasalazine and methotrexate may help peripheral arthritis
Physiotherapy:
Spinal and chest exercise
Prognosis:
Good prognosis with pain relief and exercise
BOF: 101 A 75-year-old male presents with lethargy and dizziness on standing. He gives a history of having had treatment for tuberculosis when he was young. On examination he looks underweight, his skin is pigmented and there is pigmentation of his buccal mucosa and pigmentation of the palmar creases. His nipples and areola are pigmented. There is no vitiligo. His blood pressure is 120/70 lying down and 90/60 on standing. His blood urea 10.3 mmol/L, Na 120 mmol/L, K 5.9 mmol/L Which of the following investigations is most likely to identify the aetiology of his condition?
a) 0900 ACTH level
b) Short synacthen test
c) Abdominal X-ray
d) Long ACTH stimulation test
e) Serum aldosterone /plasma renin activity
Answer: c) The patient has Addison’s disease. With the history of tuberculosis the likely aetiology is tuberculosis of the adrenal gland and this may result in calcified adrenals.
Title: Addison’s Disease
Aetiology: Inflammation
The cause of inflammation of the adrenal gland may be:
Autoimmune which could be:
• Sporadic
• Polyglandular deficiency type 1 (Addison’s disease, chronic mucocutaneous candidiasis, dental enamel hypoplasia, alopecia, primary gonadal failure)
• Polyglandular deficiency type 2 (Addison’s disease, primary hypothyroidism, primary hypogonadism, insulin-dependent diabetes mellitus, pernicious anaemia, vitiligo)
Inflammation of the adrenal gland may also occur in tuberculosis, sarcoidosis, fungal infections, cytomegalovirus infection, AIDS
Trauma bilateral adrenalectomy
Neoplasia secondary deposits, lymphoma
Vascular Lesions meningococcal septicaemia, adrenal haemorrhage, adrenal vein thrombosis
Degenerative adrenoleucodystrophy, adrenomyeloneuropathy
Metabolic haemochromatosis
Interstitial Infiltration amyloidosis
Clinical Features:
Females > Males
History:
E&M:
Weight loss
Malaise
Weakness
Fever
CVS:
Syncope due to postural hypotension
GIT:
Anorexia
Nausea and vomiting
Abdominal pain
Diarrhoea
RAG:
Impotence
Amenorrhoea
CNS:
Depression
Confusion
LMS:
Joint pains
Back pain
Myalgia
Examination:
E&M:
Decreased weight
Wasting
Salt and water loss
IS:
Buccal pigmentation
Pigmentation of palmar creases, scars
Vitiligo (autoimmune)
Loss of body hair
CVS:
Postural hypotension
Investigations:
Blood:
Hyponatraemia, hyperkalaemia, increased urea
Blood glucose low
Cortisol levels low
Short synacthen test: impaired response
0900 ACTH level: increased
Adrenal antibodies + in autoimmune adrenalitis
Serum aldosterone is decreased with increased plasma renin activity
CXR:
Tuberculosis
Abdominal X-ray:
Calcified adrenals
Management:
Drugs:
Replacement
Glucocorticoid:
Hydrocortisone, prednisolone, dexamethasone
Mineralocorticoid
Fludrocortisone
BOF: 102 A 60-year-old female is admitted with a history of syncopal episodes and breathlessness of one-week duration. No history of immobilisation or recent travel. On examination she looks distressed her conjunctiva and tongue are pale. Her pulse rate is 120 beats per minute, blood pressure 90/60, JVP elevated 5 cms. Respiratory rate 26 per minute, apex 5 LICS MCL heart sounds triple rhythm, soft systolic murmur at the left sternal edge. Lungs clear. HB 13.5 g/dL Blood gases pH 7.46 Pa CO2 3.2 kPa, Pa O2 7.7 kPa The next step in management of this patient is:
a) Immediate thrombolysis followed by an ECHO to confirm the diagnosis
b) Immediate thrombolysis followed by computerised tomographic pulmonary angiography (CTPA) to confirm the diagnosis
c) Immediate thrombolysis followed by ventilation perfusion scan to confirm the diagnosis
d) Urgent CT pulmonary angiography followed by thrombolysis
e) Full dose fragmin followed by ventilation perfusion scan
Answer: d) The clinical features in this patient suggest massive central pulmonary embolus. It is best to obtain an urgent CT PA or ECHO prior to thrombolysis. In a cardiac arrest or peri-arrest situation it may be justifiable to thrombolyse the patient and confirm the diagnosis by CTPA or ECHO if the patient survives.
BOF: 103 A 52-year-old female presents with numbness and weakness of her upper and lower limbs. She developed asthma at the age of 50 and her general practitioner treated her with steroids and antibiotics approximately one month prior to the onset of these symptoms. On examination she looks unwell. She has palpable purpura over her face and over her elbows and knees.On neurological examination she has a left sided wrist drop and there is weakness of dorsiflexion of her right hallux and weakness of dorsiflexion of her right foot. Sensation is impaired over the dorsum of her right foot.
Lungs are clear. CXR is normal
Hb 10.9 g/dL MCV 88 fl
WBC 23,000 10 9 /l
Eosinophils 12%
ANCA negative
In this patient abdominal pain could be due to:
a) Pancreatic infarction
b) Gall bladder infarction
c) Vasculitis of the gastrointestinal tract
d) Renal infarction
e) Splenic infarction
Answer: c) The patient has Churg-Strauss syndrome. The diagnosis may be made on the basis of late onset asthma, vasculitic rash and mononeuritis multiplex.ANCA is positive in approximately 60 % of the patients hence a negative ANCA does not rule out the diagnosis. In this condition vasculitis of the gastrointestinal tract may result in mass lesions that cause intestinal obstruction.
BOF: 104 A 45-year-old female presents with an 8-week history of diarrhoea with no blood or mucous, colicky abdominal pain, vomiting and loss of weight of 10 kgs. She has a history of appendicetomy and has fibromyalgia for which she has been on Diclofenac SR 75 mgs b.d. On examination she was afebrile and looked pale. The abdomen was diffusely tender but soft. Bowel sounds were normal and rectal examination was normal. Investigations showed: Hb 7.5 g/dL, MCV 70 fl CRP 235, coeliac screen negative LFTs normal, urea and electrolytes normal Colonoscopy revealed several webs with superficial ulceration in the ascending colon. Biopsies from these areas showed non-specific inflammation. In this patient, the most important aspect of treatment is:
a) Discontinue Diclofenac
b) Treat with Steroids
c) Treat with Mesalazine
d) Treat with Azathioprine
e) Treat with Ciprofloxacin
Answer: a) The patient has non-steroidal anti-inflammatory drug colopathy. This can occur after short or long term treatment with NSAIDS. These patients should be warned against any further use if NSAIDS.
BOF: 105 A 30-year-old female is under investigation for excessive weight gain. She is 1.62 m tall and weighs 80 kgs. She has central obesity with abdominal striae. She is hirsute. A dexamethasone suppression test has been performed and the results are as follows: Cortisol levels nmol/L Dexamethasone
Day 0 0900 990 8mgs
Day 1 0900 320 8mgs
Day 2 0900 130
The patient has:
a) Cushing’s disease
b) Adrenal tumour
c) Bronchial carcinoma
d) Simple obesity
e) Polycystic ovarian syndrome
Answer: a) In the dexamethasone suppression test normal individuals suppress cortisol levels to < 50 nmol/L 90 % of patients with pituitary dependent disease suppress production of cortisol to < 50 % of that on day 0 on day +2 Failure of suppression suggests ectopic ACTH production or adrenal tumour
Title: Cushing’s Syndrome
Definition: Cushing’s syndrome is condition caused by increased free circulating glucocorticoid
Aetiology:
ACTH dependent
Pituitary dependent (Cushing’s disease)
Ectopic ACTH producing tumours
Non-ACTH dependent
Adrenal adenoma
Adrenal carcinoma
Exogenous steroid
Clinical Features:
History:
E&M:
Weight gain
Growth arrest in children
KUS:
Polyuria, polydypsia
RAG:
Loss of libido
Amenorrhoea, oligomenorrhoea
CNS:
Insomnia, depression, muscular weakness
LMS:
Backache
Examination:
E&M:
Central obesity
Buffalo hump
Moon face
IS:
Hirsutism, frontal balding
Pigmentation
Thin skin
Skin infections
Poor wound healing
Striae
Bruising, plethora
CVS:
Hypertension
Oedema
CNS:
Proximal muscle weakness
LMS:
Osteoporosis
Fractures (vertebra and ribs)
Investigations:
Confirm Cushing’s
48 hour low dose dexamethasone suppression test
24 hour urinary free cortisol
Loss of circadian rhythm of cortisol secretion
Determine Cause
Adrenal CT or MRI
Pituitary MRI
High dose dexamethasone suppression test
Plasma ACTH levels
CRH test
CXR
Management:
Drugs:
Metyrapone
Ketoconazole
Aminoglutethimide
Trilostane
Chemotherapy for ACTH secreting tumours
Surgery:
Pituitary Dependent
Trans-Sphenoidal removal of pituitary tumour
Bilateral adrenalectomy (Cushing’s disease) as a last resort
Adrenal adenoma
Resection
Adrenal carcinoma
Resection or debulking
ACTH secreting tumours
Resection if possible
Radiotherapy:
Pituitary irradiation
Irradiation of ACTH secreting tumours
BOF: 106 A 14-year-old male has had a cardiac catheterisation to document the diagnosis of an abnormality of his heart. The results are as follows: Chamber Pressure in mm Hg % Oxygen saturation Superior vena cave 68 Inferior vena cave 64
Right atrium 10 82 Right ventricle 25/0 81 Pulmonary artery 25/10 81
Left atrium 10 96 Left ventricle 110/0 95 FemoralArtery 110/50 95
In this patient, on auscultation of the heart one may hear:
a) Loud single second heart sound
b) Soft single second heart sound
c) Fixed splitting of the second heart sound
d) Reversed splitting of the second heart sound
e) Varying split of the second heart sound
Answer: c) The patient has an atrial septal defect. In this condition fixed splitting of the second heart sound occurs.
BOF: 107 A 45-year-old female presents with backache. She has had a thyroidectomy for thyrotoxicosis 18 months previously. She is a vegan. Her blood results are as follows:
Hb 10.0 g/dL
Ca 1.8 mmol/L
PO4 0.72 mmol/L
Alkaline phosphatase 200 U/L
Albumin 36 g/L
Urea 6.5 mmol/L
Sodium 140 mmol/L
Potassium 3.8 mmol/L
The test that will define this patient’s condition is:
a) PTH level
b) Serum 25-hydroxy vitamin D3 level
c) Urinary calcium excretion
d) Urinary phosphate excretion
e) Iliac crest biopsy
Answer: b) The patient has osteomalacia with secondary hyperparathyroidism causing low phosphate levels.
BOF: 108 A 14-year-old male, a recent immigrant to the country is been investigated for a murmur. On examination he is in sinus rhythm, he has a loud pan systolic murmur best heard at the left sternal edge and a mid-diastolic murmur best heard at the apex. The first heart sound is not loud; there is no opening snap and no pre-systolic accentuation of the diastolic murmur.
Cardiac catheterisation results are as follows:
Chamber Pressure (mm Hg) % Oxygen saturation
Superior vena cava 66
Inferior vena cava 68
Right atrium 3.5 67
Right ventricle 35/0 80
Pulmonary artery 35/10 81
Left ventricle 100/0 96
In this patient the mid-diastolic murmur is due to:
a) Increased flow across the mitral valve
b) Increased flow across the tricuspid valve
c) Mitral stenosis
d) Tricuspid stenosis
e) Lutembacher’s syndrome
Answer: a) The patient has a ventricular septal defect. This can be deduced from the step up in oxygen saturation at the level of the right ventricle due to the left to right shunt at this level. This causes increased flow into the left atrium and this causes a flow murmur in mid-diastole. Stenosis of the mitral valve would result in a loud first heart sound, opening snap and presystolic accentuation of the murmur. Tricuspid stenosis would have caused a high pressure in the right atrium. Lutembacher’s syndrome is a combination of atrial septal defect and mitral stenosis.
BOF: 109 A 60-year-old male is under investigation for weakness of his legs, pigmentation of the skin, hypertension and glycosuria.
Results of serum cortisol estimations are;
0900 1170 nmol/l
2400 1100 nmol/l
After 48 hours of dexamethasone 8 mgs daily:
0900 1030 nmol/l
In further investigation of this patient the test most likely to identify the cause of his condition is:
a) MRI head
b) CT scan head
c) Perimetry to define visual fields
d) Chest x- ray
e) ACTH levels
Answer: d) The patient has Cushing’s syndrome with failure to suppress cortisol levels with dexamethasone. This will indicate either an adrenal tumour or an ectopic source of ACTH. Out of the list provided the most likely investigation that will determine the cause of the lesion is CXR
BOF: 110 A 31-year-old female presents with a severe headache, which woke her up from sleep at approximately 3 a.m. She has never had a headache like this before. She had a mastoidectomy several years ago. She has no other symptoms and was otherwise well; she is not pregnant and was on no drugs in particular she was not on hormonal contraception. She had not undertaken any severe exercise. On examination she was afebrile, conscious and alert. On examination of the optic fundus the cup of the optic disc was filled and the medial margins of the disc were blurred. No other CNS abnormality in particular no neck stiffness. Examination of the other systems did not reveal any abnormality. A CT scan was reported as normal by the duty radiology registrar, Full Blood Count was normal. In this patient the investigation that is likely to lead to a diagnosis is:
a) MR venogram
b) Lumbar puncture
c) Vitamin A level
d) Cisternal puncture
e) E.S.R.
Answer: a) The patient has sagittal sinus thrombosis. This can be secondary to Thrombophilia, which may be primary or secondary to diseases such as nephrotic syndrome, paroxysmal nocturnal haemoglobinuria. It can also occur in pregnancy and in patients taking hormonal contraception. Dehydration is another cause. It may be secondary to sinusitis and mastoiditis or it may be idiopathic.
In this patient the treatment of choice would be:
a) Heparin
b) Steroids
c) Vitamin A
d) Acetazolamide
e) Repeated lumbar puncture
Answer: a) Sagittal sinus thrombosis is beat treated with heparin. There are reports in the literature of successful thrombolysis by local instillation of thrombolysis.
BOF: 111 A young female who is short, plump and has a rounded facies has the following haematology and biochemical profile:
Hb 12.8 g/dl
Serum Calcium 1.62 mmol/l
Serum Phosphate 2.9 mmol/l
Creatinine 44 micromoles/l
Albumin 38 g/l
Which radiological abnormality is likely in this patient?
a) Defective mineralisation of the pelvis
b) Looser’s zones
c) Nephrocalcinosis
d) Subperiosteal erosions in the middle or terminal phalanges of the hands
e) Short fourth and fifth metacarpals
Answer: e) The patient has pseudohypoparathyroidism, which is associated with short metacarpal bones Looser’s zone are linear areas of low density surrounded by sclerotic borders. This and defective mineralisation of the pelvis are x-ray features of osteomalacia. Nephrocalcinosis and subperiosteal erosions occur in hyperparathyroidism
BOF: 112 A 60 year old male presents with backache and discomfort in his pelvis. He is a widower and lives alone in a small flat.
Investigations are as follows:
Serum calcium 1.9 mmol/l
Serum phosphate 0.6 mmol/l
Alkaline phosphatase 140 U/l
Urea 5.5 mmol/l
Albumin 36 g/l
In this patient the following x-ray changes are likely:
a) Calcification of the basal ganglia
b) Pseudofractures of the pubic rami
c) Osteoporosis circumscripta
d) Rounded lytic lesions in the skull
e) Nephrocalcinosis
Answer: b) The patient has osteomalacia. The x-ray feature that may occur in this condition is pseudofracture of the pubic rami.Calcification of the basal ganglia is a feature of hypoparathyroidism. Osteoporosis circumscripta refers to a front of resorbing bone in the skull. It occurs in Paget’s disease of bone. Rounded lytic lesions in the skull occur in myeloma. Nephrocalcinosis is a feature of hyperparathyroidism.
BOF: 113 A 74-year-old male who is known to have ischaemic heart disease and has had a myocardial infarction presents with breathlessness. His extremities are cold and clammy; his pulse rate is 120 beats per minute, blood pressure 80/40. JVP elevated, heart sounds triple rhythm, crepitations are heard in both bases.
Investigations show:
pH 7.24
Pa O2 8.5 kPa
Pa CO2 4.4 kPa
Blood lactate 5.9 mmol/l
Urine pH 5.2
Urine osmolarity 320mmol/l
Blood glucose 8.6 mmol/l
In this patient the abnormal acid-base balance is due to:
a) Aspirin overdose
b) D-lactic acidosis
c) Type A L-lactic acidosis
d) Type B L-lactic acidosis
e) Diabetic ketoacidosis
Answer: c) Type A L-lactic acidosis occurs when excess lactic acid is formed by anaerobic metabolism. Type B L-lactic acidosis is due to decreased hepatic lactate metabolism caused by insulin deficiency, drugs such as biguanides, haematological malignancies, enzyme deficiencies. D-lactic acidosis is caused by bacterial fermentation in the gut in the short bowel syndrome.
BOF: 114 A 56-year-old female presents with a history of increasing tiredness. On examination there is pigmentation of her skin creases and buccal mucosa. Her blood pressure is 90/50.
Investigations are as follows:
Blood urea 8.4 mmol/l
Na 130 mmol/l
Potassium 6.1 mmol/l
Chloride 96 mmol/l
Bicarbonate 23 mmol/l
Which of the following tests will confirm the diagnosis?
a) Random cortisol measurement
b) Short ACTH stimulation test
c) Long ACTH stimulation test
d) 0900 Plasma ACTH level and cortisol measurement
e) Abdominal x-ray
Answer: d) This patient has Addison’s disease. A high 0900 h plasma ACTH level with low or normal cortisol will confirm the diagnosis of primary hypoadrenalism The short ACTH (synacthen) test would show that the adrenal gland is not responding to ACTH. This may be due to primary hypoadrenalism or secondary to adrenal suppression by steroids or ACTH deficiency. Hence it will not confirm the diagnosis. She does not have adrenal suppression by steroids or ACTH deficiency as her skin creases and buccal mucosa are pigmented. Hence, a long ACTH stimulation test is not the answer.
BOF: 115 A young female has the following somatic features:
Short stature, round face, short neck, short fourth and fifth metacarpals and metatarsals
Her investigations are as follows:
Serum calcium 2.2 mmol/l
Serum phosphate 1.2 mmol/l
Alkaline phosphatase 100 U/L
Urea 4.0 mmol/L
Creatinine 90 mmol/L
The diagnosis is:
a) Pseudohypoparathyroidism
b) Hypoparathyroidism
c) Rickets
d) Vitamin D resistant rickets
e) Pseudopseudohypoparathyroidism
Answer: e) This patient has the somatic features of pseudohypoparathyroidism but biochemistry is normal indicating pseudopseudohypoparathyroidism
BOF: 116 A 50-year-old male who is known to have chronic bronchitis presented to the accident and emergency department. After initial treatment he was sent up to the ward. His blood gases on admission to the ward were as follows:
pH 7.22
PaO2 14.4 kPa
PaCO2 18.8 kPa
The physical sign that alerted the examining clinician to this condition was:
a) Tachycardia
b) Pulsus paradoxus
c) Flapping tremor
d) Elevated JVP
e) Fourth heart sound
Answer: c) A flapping tremor is indicative of hypercapnia
BOF: 117 A 35-year-old female has been on treatment for depression. She complains of constipation. Her blood results are as follows:
Serum calcium 2.77 mmol/l
TSH 20 mU/l
Which drug is responsible for these features?
a) Amitryptiline
b) Fluoxetine
c) Venlafaxine
d) Mirtazepine
e) Lithium
Answer: e) Lithium can causes hypercalcaemia and hypothyroidism. Lithium can increase serum calcium, reduce serum phosphorous, and increase PTH 10-15 % patients will develop slightly elevated Ca and PTH within 4 weeks of starting treatment with lithium. These values may reverse within one week of lithium discontinuation
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