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1. An 80 year old man previously fit healthy presents severe flinging movements of left

1. An 80 year old man previously fit healthy presents severe flinging movements of

left arm.Where is the neurological lesion?

1

1 ) Caudate nucleus

1 . An 80 year old man previously fit healthy presents severe flinging movements of

1 .

An 80 year old man previously fit healthy presents severe flinging movements of

left arm.Where is the neurological lesion?

1 ) Caudate nucleus

2 ) Globus pallidus

3 ) Ipsilateral thalamus

4 ) Substantia nigra

5 ) Subthalamic nucleus

Comments:

The presence of severe flinging movements indicating hemibalistic movements. The site of

lesion

contralateral subthalamic nucleus. The commonest cause infarction. Usually flinging

movements stop spontaneously in next 4 8 weeks. Tetrabenazine

t reatment of choice. 5 )

2. A 52 year old man presented acute dyspnoea. His past history includes 3 vessel coronary

artery bypass surgery Ischaemic Heart Disease hypertension. Examination widespread expiratory

crackles chest X ray confirming pulmonary o edema. He was treated intravenous nitrates

frusemide symptomatic improvement. Investigations at this stage revealed:

Serum sodium

138

mmol/L

 

Serum potassium

4.2

mmol/L

Serum urea

8.7

mmol/L

Serum creatinine

170

umol/L

Random plasma glucose

10.1

mmol/L

Urinalysis Protein

++

The following day he was switched oral frusemide at a dose of 80 mg daily began Captopril 12.5

mg twice daily, increased 25 mg twice daily. Repeat investigations one week later revealed :

Serum sodium

134

mmol/L

 

Serum potassium

5.1

mmol/L

Serum urea

15.7

mmol/L

Serum creatinine

220

umol/L

Fasting plasma glucose

6.0

mmol/L

Which of following

1 ) Captopril

2 ) Cholesterol emboli

likely be responsible

3 ) Diabetic nephropathy

4 ) Frusemide

5 ) Hypertension

Comments:

deterioration in renal function?

This patient coronary artery atheroma therefore could have a renal artery stenosis by same

pathophysiological mechanism. A rise in serum creatinine more than 20% above baseline after

starting an ACEI should p rompt clinician stop drug, monitor renal function. The patient does

have diabetes based upon a fasting plasma glucose of only 6 mmol/l. 1 )

3 .

A 14 year old girl admitted headache, nausea vomiting. She had previously well but

her symptoms deteriorat ed over last 12 hours.

On admission, she noted be slightly confused a temperature of 39 degrees centigrade,

3

stiff neck positive Kernig’s sign a faint purpuric rash on knees. Her pressure 90/60

mmHg a pulse of 120 beats per minute.

2

) Globus pallidus

3 ) Ipsilateral thalamus

4 ) Substantia nigra

5 ) Subthalamic nucleus

Comments:

The presence of severe flinging movements indicating hemibalistic movements. The site of

lesion

movements stop spontaneously in next 4 8 weeks. Tetrabenazine

contralateral subthalamic nucleus. The commonest cause infarction. Usually flinging

treatment of choice. 5 )

2. A 52 year old man presented acute dyspnoea. His past history includes 3 vessel coronary

artery bypass surgery Ischaemic Heart Disease hypertension. Examination widespread expiratory crackles chest X ray confirming pulmonary oedema. He was treated intravenous nitrates frusemide symptomatic improvement. Investigations at this stage revealed:

Serum sodium

138

mmol/L

Serum potassium

4.2

mmol/L

Serum urea

8.7

mmol/L

Serum creatinine

170

umol/L

Random plasma glucose

10.1

mmol/L

Urinalysis Protein

++

The following day he was switched oral frusemide at a dose of 80 mg daily began Captopril 12.5 mg twice daily, increased 25 mg twice daily. Repeat investigations one week later revealed:

Serum sodium

134

mmol/L

Serum potassium

5.1

mmol/L

Serum urea

15.7

mmol/L

Serum creatinine

220

umol/L

Fasting plasma glucose

6.0

mmol/L

Which of following

1 ) Captopril

likely be responsible

2 ) Cholesterol emboli

3 ) Diabetic nephropathy

4 ) Frusemide

5 ) Hypertension

deterioration in renal function?

Comments:

This patient coronary artery atheroma therefore could have a renal artery stenosis by same pathophysiological mechanism. A rise in serum creatinine more than 20% above baseline after

starting an ACEI should prompt clinician stop drug, monitor renal function. The patient does have diabetes based upon a fasting plasma glucose of only 6 mmol/l. 1 )

3. A 14 year old girl admitted headache, nausea vomiting. She had previously well but

her symptoms deteriorated over last 12 hours. On admission, she noted be slightly confused a temperature of 39 degrees centigrade, stiff neck positive Kernig’s sign a faint purpuric rash on knees. Her pressure 90/60 mmHg a pulse of 120 beats per minute. A diagnosis of meningococcal meningitis confirmed following CT headscan lumbar puncture. She admitted ITU treated IV cefotaxime 2g tds Benzylpenicillin 2.4g qds. She a rather stormy admission requiring intubation, ventilation hypotensive episodes. On day 2 of her admission, her urine output falls hourly urine output of approximately 10 mls/hr.

4

Investigations reveal:

Haemoglobin

16.7g/dL

White cell count

16.8

x109/L

Platelets

100

x109/L

Serum sodium

125

mmol/L

Serum potassium

5 mmol/L

Serum urea

6.7

mmol/L

Serum creatinine

100

umol/L

Plasma osmolality

300

mosmol/L

Urine osmolality

325

mosmol/L

Urine urea

120

mmol/L

Urine sodium

75 mmol/L

Select two reasons why this acute tubular necrosis is pre renal failure?

1 ) Her pressure low

2 ) Her haemoglobin 16.7

3 ) Her plasma sodium 125 mmol/l

4 ) Her urine plasma osmolality ratio >1.1

5 ) Her urine plasma urea ratio elevated

6 ) Her urine plasma osmolality ratio reduced

7 ) Her urine output falls

Comments:

In ATN, urine plasma osmolality should be < 1.1, urinary sodium excretion typically >60mmol/L urinary urea excretion <160mmol/L. If this patient had a physiological oliguria,

there would still be preservation of urine concentration, low urinary sodium. Both ATN pre

renal failure can present a fall in urine output. There such a marked variation in urine urea concentration, it seldom used as a clinical guide. 3 ) 6)

4. A 52 year old man presented acute dyspnoea. His past history includes 3 vessel

coronary artery bypass surgery Ischaemic Heart Disease. Examination widespread expiratory crackles chest X ray confirming pulmonary oedema. He was treated intravenous nitrates frusemide symptomatic improvement. Investigations at this stage revealed:

Serum sodium

138

mmol/L

Serum potassium

4.2

mmol/L

Serum urea

8.7

mmol/L

Serum creatinine

170

umol/L

Random plasma glucose

10.1

mmol/L

Urinalysis Protein

++

The following day he was switched oral frusemide at a dose of 80 mg daily began Captopril 12.5 mg twice daily, increased 25 mg twice daily. Repeat investigations one week later revealed:

Serum sodium

134 mmol/L

Serum potassium

5.1 mmol/L

5

Serum urea

15.7 mmol/L

Serum creatinine

220 umol/L

Fasting plasma glucose

6.0 mmol/L

Which

next best investigation in determining the cause of his renal failure?

1 ) Captopril renogram

2 ) Doppler of renal arteries

3 ) Renal angiography

4 ) Renal biopsy

5 ) Renal isotope scan

Comments:

This patient coronary heart disease. Renal function deteriorated in presence of an ACEI it important exclude atheroma of renal arteries causing renal artery stenosis. Renal angiography, particularly MR angiography a good way diagnose renovascular disease without having

administer nephrotoxic contrast, but as gold standard, percutaneous angiography

of choice, also enables angioplasty, if indicated. Renal artery Doppler prone more false

investigation

negative results than angiography. 3 )

5. A 40 year male ulcerative colitis(UC) of 10 years duration presented feeling unwell.

He complained of right upper quadrant pain

are pale coloured. He on sulphasalazine

On examination he 5 spider naevi on upper trunk. In his abdomen he a 5 cm hepatomegaly a tipable spleen, but no ascites.

recently noticed he started itch. His stools

had only 2 previous minor relapses.

Platelets

110

x 109/L

Prothrombin time

20

sec

Serum bilirubin

55

umol/L

Serum aspartate aminotransferase

101

IU/L

Serum alanine aminotransferase

38

IU/L

Serum alkaline phosphatase

482

IU/L

Hepatitis B surface antigen

Negative

What is the likely diagnosis?

1 ) Colonic carcinoma

2 ) Drug cholestasis

3 ) Cholangiocarcinoma

4 ) Primary biliary cirrhosis

5 ) Primary sclerosing cholangitis

Comments:

This man cirrhosis portal hypertension, cholestasis liver synthetic failure. Primary sclerosing

cholangitis(PSC) a strong association ulcerative colitis

risk of cholangiocarcinoma PSC, it possible his deterioration may be due

cholangiocarcinoma. Drug cholestasis would explain stigmata of chronic liver disease (spiders,

splenomegaly)., neither would colonic carcinoma. Primary biliary cirrhosis uncommon in men. 5 )

6. A 56 year

left hand. She noted wasting in right hand muscles. She was well controlled on Penicillamine. On examination there was inversions of biceps supinator jerks. The triceps

likely diagnosis. There an increased

development of

associated UC

long standing rheumatoid arthritis presented pain in neck radiating

6

jerk was brisk. Knee reflexes were present. The plantars were equivocal because of rheumatoid arthritis of Hallux. Fasciculation's were noted, neck movements were restricted, position sense was slightly impaired.Where is the lesion located?

1 ) Cervico medullary junction

2 ) C1,2

3 ) C5,6

4 ) C7,8

5 ) C8,T1

Comments:

Neck pain radiating

(C5) supinator (C6) jerks indicating level of lesion at C5,6. The reflexes below lesion (i.e.)

triceps (C7) are brisk. 3 )

7. A 14 year boy of white Irish parents admitted haematemesis. Gastroscopy demonstrates

bleeding oesophageal varices. Despite being born prematurely at 32 weeks he

until presentation.On examination there are peripheral stigmata of chronic liver disease, but there a palpable spleen 4 cm below costal margin. nvestigations showed:

hand indicating a radiculopathy. The fact there was inversion of biceps

completely well

Hepatic wedge pressure

6 mmHg (normal <7)

Inferior vena cava

3 mmHg (normal <5)

Which

1 ) Ultrasound Doppler flow of hepatic portal veins

2 ) Splenoportogram

3 ) Liver biopsy

4 ) Laparoscopy

5 ) MRI scan liver

best initial investigation perform?

Comments:

This child likely have portal vein thrombosis resulting from neonatal cannulation of his

umbilical vein following his premature delivery. PV thrombosis should be easily demonstrated on Ultrasound which a cheap non invasive procedure, one would hope this would be performed prior considering hepatic venous pressure studies ! 1 )

8. A 68 year old man was admitted nausea general malaise He was a hill farmer

continued work his farm his sons on which he kept mostly sheep. Over last two weeks, since returning from Holiday in Spain, he had become increasingly fatigued. The only other symptoms of note were a 3 month history of poor appetite a 8 kg weight loss. He was receiving thyroxine 100 mcgm daily having diagnosed hypothyroidism by his GP 9 years previously. He was a smoker of 5 cigarettes per day had drunk more alcohol than usual

whilst on holiday but usually drank about 12 units of alcohol daily. On examination, he was sun tanned, slightly confused, appeared dehydrated had a pulse of 92 bpm regular, a temperature of 37.2oC a pressure of 100/80 mmHg. Cardiovascular respiratory examination were unremarkable. He had a slight liver edge on palpation neurological examination was normal. Investigations revealed:

Serum sodium

125 mmol/L

 

Serum potassium

5.6 mmol/L

 

Serum corrected calcium

2.73 mmol/L

 

Serum standard bicarbonate

15

mmol/L

 

Serum urea

22

mmol/L

 

Plasma TSH

6 mU/L

(NR 0.4 4.0)

7

Which of following

likely diagnosis?

1 ) Bronchogenic carcinoma Syndrome of Inappropriate ADH secretion.

2 ) Hypoadrenalism

3 ) Hypothyroidism

4 ) Primary hyperparathyroidism

5 ) Sarcoidosis

Comments:

This farmer a three month history of weight loss, anorexia fatigue. He recently returned from Spain but this a distractor as his occupation. The investigations show hyponatraemia, hyperkalaemia, uraemia, hypercalcaemia slightly elevated TSH which suggest diagnosis of Hypoadrenalism. He known have an autoimmune disease – hypothyroidism a diagnosis of Addison‟s suggested. Slight elevation of TSH a mild hypercalcaemia are typical of hypoadrenalism. Bronchogenic Carcinoma SIADH would be

expected produce a hyponatraemia but

The patient‟s symptoms do fit hypothyroidism (weight loss)

be expected. Although sarcoidosis may produce hypercalcaemia, hyponatraemia would be a typical finding respiratory signs may be expected. Primary hyperparathyroidism would produce

such problems such a calcium concentration. 2 )

potassium urea.

uraemia hyperclacaemia would

9. A 27 year old refugee from Cambodia presents a short history of fatigue jaundice.

He lived in UK last 12 months. His mother died of liver disease age 55 his older brother died of liver cancer 3 years previously in Cambodia age 40. His brother was known have hepatitis B. He consumes 30 40 units of alcohol a week.

Investigations show:

Haemoglobin

14.5 g/dL

 

WBC

7.6 x 109/L

 

Platelets

156

x 109/L

 

Serum bilirubin

213

umol/L

 

Serum gamma glutamyl transferase

200

IU/L

 

Serum alkaline phosphatase

150

IU/L

 

Serum aspartate aminotransferase

912

IU/L

 

Serum alanine aminotransferase

1450 IU/L

 

Serum alpha fetoprotein

45 kU/L

(NR < 10)

HbsAg

Positive

 

HBeAg

Positive

Anti HBc (IgM)

Positive

Anti HAV (IgM)

Negative

Anti HAV (IgG)

Positive

Anti HCV

Negative

8

An ultrasound scan of his liver shows mild hepatomegaly an echogenic liver but other abnormality.What is the likely diagnosis?

1 ) Alcohol related hepatitis

2 ) Acute Hepatitis B

3 ) Flare of chronic Hepatitis B

4 ) Hepatocellular cancer

5 ) Hepatitis E

Comments:

This man's brother was known have HBV it likely their mother was also infected given her demise from liver disease at a young age. In developing countries, vertical transmission from mother child commonest mode of acquiring chronic HBV infection. It likely this patient chronic infection now in Immune clearance phase of chronic infection a severe flare of his

hepatitis. He likely clear HBeAg during this illness. Although Anti HBc (IgM) usually associated acute infection it often seen in acute flares of chronic disease. The ALT too high alcohol related hepatitis. The AFP commonly elevated during acute hepatitis due hepatic regeneration HCC unlikely in a 27 yr would account raised ALT. Hepatitis E endemic in UK a very unlikely diagnosis. 3 )

10. A 56 year

long standing rheumatoid arthritis presented pain in neck radiating

left hand. She noted wasting in right hand muscles. She was well controlled on Penicillamine. On examination there was inversions of biceps supinator jerks. The triceps jerk was brisk. Knee reflexes were present. The plantars were equivocal because of rheumatoid arthritis of Hallux. Fasciculation's were noted, neck movements were restricted, position sense was slightly impaired.What is the likely diagnosis?

1 ) Atlanto axial subluxation

2 ) B12 deficiency

3 ) Cervical cord tumour

4 ) Cervical myelopathy

5 ) Motor neurone disease

Comments:

The presence of inversion of biceps supinator reflexes indicating cervical myelopathy at C5, 6. This a very important sign which distinguish cervical myelopathy from motor neuron disease. 4 )

11. A 50 year old man presents tingling in left upper limb. The pain originated in neck

radiated down left arm. He proceeded have numbness paraesthesia in left lower limb. On examination he had restriction of neck movements there was a mild wasting be noted in left biceps. There was inversion of supinator biceps jerks. His knee jerk ankle jerk were hyper reactive he a positive extensor plantar response. He then developed paraesthesia numbness of right lower limb. A diagnosis of cord compression was made he underwent a surgical decompression. Post surgery was complicated by septicaemia urinary tract infection he remained in bed 4 days. He subsequently developed inability dorsiflex his right foot right big toe. There was numbness on outside of foot there was decreased eversion, but inversion was normal. His reflexes remained as before.What is the cause cause of his problem?

1 ) Common peroneal nerve palsy

2 ) L4 root lesion

9

3

) Recurrence of original cord compression

4 ) Spinal cord infarction

5 ) Sciatic nerve palsy

Comments:

The commonest cause of acute foot drop after prolonged bed rest entrapment common peroneal neuropathy at neck of fibula. Typically there weakness of ankle dorsiflexion, eversion,

diminished sensation of lateral aspect of leg dorsum of foot. The ankle reflex remains intact. 1 )

12. A 40 year male ulcerative colitis of 10 years duration presented feeling unwell. He

complained of right upper quadrant pain

pale coloured. He on sulphasalazine

On examination he five spider naevi on upper trunk. A liver edge palpable 5cm below right costal margin. The tip of spleen also palpable but there are signs of ascites.

recently noticed he started itch. His stools are

had only 2 previous minor relapses.

Platelets

110

x 109/L

 

Prothrombin time

20

sec

(Control 11.5 15.5)

Serum bilirubin

55

umol/L

 

Serum aspartate aminotransferase

101

IU/L

 

Serum alanine aminotransferase

38

IU/L

 

Serum alkaline phosphatase

482

IU/L

 

Hepatitis B surface antigen

Negative

 

Which investigation is likely to confirm the diagnosis ?

1 ) Liver ultrasound

2 ) Liver biopsy

3 ) ERCP

4 ) Anti mitochondrial antibodies

5 ) Withdrawal of sulphasalazine

Comments:

This man PSC, a diagnosis made on ERCP ( intra

ultrasound likely show a cirrhotic looking liver but confirm a cause. Liver biopsy will confirm

extra hepatic bile duct stricturing). Liver

biliary cirrhosis but does provide information on whether there a dominant extra hepatic

stricture which may be amenable endoscopic intervention. AMA‟s are associated PBC PSC. Withdrawal of his medication will be of benefit as this chap established liver disease due PSC rather than drug related cholstasis. 3 )

13. A 28 year trainee accountant presents weight loss of one stone in 4 weeks,

diarrhoea mild abdominal pain. He had not travelled abroad recently. On examination he

had an aphthous ulcer on soft palate.

Haemoglobin

9.7 g/dL

 

MCV

70

fL

 

Serum corrected calcium corrected

2.05 mmol/L

 

Serum total protein

65

g/L

 

Serum albumin

34

g/L

 

Serum IgG

15

mg/L

(NR 6 13)

Serum IgA

< 0.1 mg/L

(NR 0.8 3.0)

10

Serum IgM

2.0g/L

(NR 0.4 2.5)

Anti endomesial IgA antibody

   

What is the likely diagnosis?

1

) Coeliac disease

2

) Crohn‟s disease

3

) Ulcerative colitis

4

) Intestinal lymphoma

5

) Whipple‟s disease

Comments:

This patient selective Ig A deficiency, a known association coeliac disease. The symptoms, iron deficiency anaemia, aphthous mouth ulceration are all features of coeliac disease. The anti endomysial IgA negative because patient IgA deficient. Anti Tissue transglutaminase (IgG) testing should be performed. 1 )

14. A 42 year old widow presents a one week history of progressive confusion unsteady

gait. She works as a barmaid lives in poor social circumstances. On examination she malnourished disorientated. She nystagmus unable abduct either eye. The pupils are sluggish unequal. Ankle jerks are absent but upper limb reflexes are present. Shortly after her admission you are called ward as she become very drowsy collapsed on floor. Investigations on admission showed:

Haemoglobin

11.4 g/dL

MCV

99

fL

White cells

5.6

x109/L

Platelets

230

x109/L

Serum sodium

129

mmol/L

Serum potassium

3.2

mmol/L

Serum bilirubin

27

umol/L

Serum gamma glutamyl transferase

440

IU/L

Serum alkaline phosphatase

180

IU/L

Serum aspartate aminotransferase

90

IU/L

Serum alanine aminotransferase

45

IU/L

Serum albumin

33

g/L

Prothrombin time

12

sec

The first investigation should be:

1 ) CT head

2 ) Blood glucose

3 ) EEG

4 ) Blood cultures

5 ) B12 folate levels

Comments:

11

Wernicke‟s encephalopathy

background of likely alcoholism. Although all of above investigations may need be considered

exclude other contributing aetiologies her presentation only

cheaply at bedside. Hypoglycaemia may have precipitated her deterioration a finger prick glucose estimation should be first investigation. 2 )

15. A 40 year male presents an elective ERCP a common bile duct stone. Post ERCP he

develops acute septicaemia.

likely diagnosis given history examination findings on a

glucose can be done quickly

Pre ERCP

Serum sodium

136

mmol/L

Serum potassium

4

mmol/L

Serum chloride

100

mmol/L

Serum bicarbonate

28

mmol/L

Serum urea

4

mmol/L

Serum creatinine

96

umol/L

Post ERCP

Serum sodium

140

mmol/L

Serum potassium

4 mmol/L

Serum chloride

100

mmol/L

Serum bicarbonate

26 mmol/L

Serum urea

40

mmol/L

Serum creatinine

720

umol/L

All physical findings are

Based on recent clinical trials which one of the following is evidenced based?

his chest clinically clear. He producing 40 ml of urine per hour.

1 ) Give high dose frusemide

2 ) Give low dose dopamine

3 ) Give low dose dopamine, frusemide mannitol

4 ) Give frusemide mannitol

5 ) None of above

Comments:

This man post ischaemic, non oliguric renal failure due sepsis. There

clinical trials support use of any of above agents. There some evidence from animal studies these agents given early in septicaemia may help prevent renal damage. The use of dopamine,

frusemide, mannitol in acute renal failure remains controversial. 5 )

clear evidence from

16. A 78 year old man presented an unsteady gait. He was noted be becoming impaired

his memory agitated at nights. His GP started an antidepressant. He was incontinent of

urine. He was a heavy smoker had lost 2 stones in weight over 2 months. His sugar was 10 mmol/l. Which of the following is the next best investigation?

1 ) CT Head

2 ) CXR

3 ) Glycosylated Hb

12

4

) Thyroid function test

5 ) Urinary Sodium

Comments:

The triad of unsteady gait, memory impairment urinary incontinence suggests diagnosis of

pressure hydrocephalus. CT head of brain of proportion of cerebral atrophy. 1 )

investigation of choice show enlarged ventricles out

17. An 18 year old presented bilateral ptosis tiredness towards afternoons. She had a

short tensilon (edrophonium test which was positive). A diagnosis of myasthenia Gravis was made she was stated on pyridostigmine. She now relapses given edrophonium intravenously. However her condition deteriorates her forced expiratory volume falls 1.0. She transferred high dependency units. An initial CT scan chest x ray were normal. What should be the next management step?

1 ) Azathioprine

2 ) Emergency thymectomy

3 ) Intravenous methylprednisolone

4 ) Neostigmine

5 ) Plasmaphoresis

Comments:

The diagnosis Myasthenia crisis. The treatment of choice either iv immunoglobulins plasma

exchange. Transfer ITU essential because patients may deteriorate rapidly needing intubation ventilation. 5 )

18. A 14 year boy of white Irish parents admitted haematemesis. Gastroscopy

demonstrates bleeding oesophageal varices. Despite being born prematurely at 32 weeks he completely well until presentation. On examination there are peripheral stigmata of chronic liver disease, but there a palpable spleen 4 cm below costal margin. Invasive venous pressures are as follows:

Hepatic wedge pressure

6 mmHg (normal <7)

Inferior vena cava

3 mmHg (normal <5)

What is the likely diagnosis?

1 ) Sarcoidosis

2 ) Longstanding portal vein thrombosis

3 ) Hepatic vein thrombosis

4 ) Schistosomiasis

5 ) Alpha one antitrypsin deficiency

Comments:

The hepatic venous pressure gradient (normal HVPG = 1 5 mmHg) means

portal hypertension

related post sinusoidal intrinsic liver disease such as cirrhosis (caused in children by metabolic

disorders such as A1ATD ) post hepatic venous obstruction (HV thrombosis). The obstruction must be pre sinusoidal. Sarcoidosis a very rare cause of pre sinusoidal portal hypertension, particularly in white children. Schistosomiasis leading cause of pre sinusoidal hypertension worldwide but unlikely in an Irish boy. Thrombosis of portal vein a well recognised complication in premature neonates due cannulation of umbilical vein during neonatal intensive care. 2 )

13

19.

A 50 year old male presents a 4 weeks history of exertional shortness of breath. He

a long history of depression which he originally took Lithium Carbonate but stopped this medication over 5 years ago since then taking Paroxetine. He was also diagnosed asthma 2 years ago by his general practitioner which he was prescribed salbutamol inhalers taking ibuprofen over last six months Osteoarthritis of hips. The only other relevant information two weeks ago he returned from a 6 week holiday in Australia where he spent a week in outback. He had frequently been bitten by mosquitoes. Examination reveals a rather ill and tanned individual a temperature of 37oC, a pressure of 146/86 mmHg a pulse of 106 beats per minute. No specific abnormalities were noted except scattered bibasal fine crackles occasional wheeze on chest examination. Investigations reveal:

Haemoglobin

14g/dL

White cell count

6

x 109/L

Neutrophil count

3.5x109/L

Lymphocyte coun

2

x 109/L

Monocyte count

normal

Eosinophils

1

x 109/L

ESR (Westergren)

65 mm/1st hour

Serum sodium

136

mmol/L

Serum potassium

7.0 mmol/L

Serum chloride

106

mmol/L

Serum bicarbonate

15 mmol/L

Serum creatinine

600

umol/L

Ultrasound of kidneys:

Right kidney 12cm, left kidney 13cm. No obstruction seen What is the likely diagnosis?

1 ) Amyloid

2 ) Analgesic nephropathy

3 ) Churg Strauss syndrome

4 ) Membranous glomerulonephritis

5 ) Rapidly progressive glomerulonephritis

Comments:

This patient may have an inflammatory pathology as indicated by ESR. He developed asthma in presence of a raised peripheral eosinophil count. The presence of above renal impairment lends a possible diagnosis of Churg Strauss syndrome, which can cause a pauci immune small vessel vasculitis, glomerulonephritis. ANCA titres should be checked.3 )

14

1. A 52 year old presents tiredeness, weight loss, anxiety difficulty sleeping. She was receiving

1. A 52 year old presents tiredeness, weight loss, anxiety difficulty sleeping. She was

receiving a combined cyclical oestrogen/progesterone hormone replacement therapy. Examination a thin patient a pulse of 110 beats per minute, a fine tremor proximal myopathy. Her spleen tip

was barely felt. Initial investigations showed:

Serum total thyroxine

250

nmol/L

(NR 60 140)

Plasma TSH

< 0.1 mU/L

(NR 0.4 4.0)

Serum alkaline phosphatase

202

IU/L

(NR 50 100)

Serum gamma glutamyl transferase

40 IU/L

(NR 10 50)

The general practitioner commenced Carbimazole 20 mg twice daily together propranolol. On review six weeks later she looked euthyroid. Repeat investigations showed:

Serum total thyroxine

180

nmol/L

Plasma TSH

2.2 mU/L

Serum alkaline phosphatase

160

IU/L

Serum gamma glutamyl transferase

35 IU/L

The dose of carbimazole was decreased 20 mg daily. After one year’s treatment where

patient felt increasingly tired, GP decided refer her

appointment she had developed a chest infection which her GP had prescribed

erythromycin. At clinic following results were noted:

outpatient. Two weeks prior her

Serum total thyroxine

80

nmol/L

Plasma TSH

10.2 mU/L

Serum alkaline phosphatase

102 IU/L

Serum gamma glutamyl transferase

36

IU/L

What is the cause of her elevated Alkaline Phosphatase?

1 ) Osteoporosis

2 ) Oestrogen therapy

3 ) Paget‟s disease

4 ) Progestogen therapy

5 ) Thyotoxicosis

Comments:

High bone turnover osteoporosis may be associated thyrotoxicosis. Bone turnover involves increased osteoclastic osteoblastic activity, leading elevated alkaline phosphatase levels derived from bone. Paget‟s disease associated raised alkaline phosphatase but one should apply Ockham‟s Razor find two diagnoses when there one unifying diagnosis. Osteoporosis associated a raised alkaline phosphatase under circumstances. 5 )

2. A 62 year old woman referred a three month history of increasing weakness affecting left

more than right arm. She also complains of tingling numbness affecting left thumb which tends be worse at nights. She dropped cups of tea twice in last month but attributes this her own clumsiness. She denies any visual, speech, bowel bladder symptoms. Occasionally she gets some

15

neck discomfort on turning her head but denies any recent past history of neck trauma. Past history includes a left mastectomy 10 years ago breast cancer. Her sister died of a brain tumour. On examination, her cranial nerves are intact. No increase in tone detectable in all limbs. She mild weakness when flexing supinated forearm against resistance, diminished biceps brachioradialis reflexes increased triceps reflexes bilaterally. The rest of her muscle power reflexes are normal. Plantar responses are flexor bilaterally. Sensory examination unremarkable pinprick joint position sense. What is the likely diagnosis in this woman?

1 ) Amyotrophic lateral sclerosis

2 ) Cervical myelopathy

3 ) Hereditary spastic paraparesis

4 ) Multiple sclerosis

5 ) Ulnar nerve entrapment

Comments:

The symptoms in this patient best fit a spondylotic problem affecting C5/6 level, thus C6 cervical root. Symptoms signs of a C6 root lesion include paraesthesias in thumb lateral distal forearm, weakness of brachioradialis, biceps, triceps diminished biceps brachioradialis reflexes in conjunction an increased triceps reflex. Patients do always present all of these features but key finding here inverted upper limb reflexes (brisk triceps diminished biceps brachioradialis). The presence of sensory symptoms make amyotrophic lateral sclerosis unlikely. Ulnar nerve entrapment does cause reflex changes. Hereditary spastic paraparesis usually begins in lower limbs patient a bit it only start manifesting now. Multiple sclerosis also less common in this age group. 2 )

3. A 78 year

but recently seen gynaecologists incontinence at which point hypertension was noted. Examination reveals a well patient a BMI of 25, a pulse of 80 beats per minute, a pressure

of 188/78 mmHg heart sounds. Fundal examination reveals silver wiring. Which of following class of drugs would be the appropriate treatment of this patient’s hypertension?

referred

out patient department hypertension. She generally very well

1 ) ACE inhibitor

2 ) Alpha Blockers

3 ) Beta blocker

4 ) Calcium antagonist

5 ) Thiazide diuretic

Comments:

This elderly

isolated systolic hypertension (systolic greater than 160 diastolic below 90

mmHg). Evidence from studies such as Systolic Hypertension in Elderly Program Syst Eur

indicate both thiazides calcium antagonists are drugs of choice in terms of reducing morbidity mortality in this patient group. In this patient‟s case incontinence may be exacerbated by diuretic therapy a calcium antagonist may be more appropriate. 4 )

4. An eighteen year student presented sudden onset of left sided chest pain

breathlessness. He had a history of cardiac surgery as a child. He smoked ten cigarettes a day. He denied any alcohol elicit drug use. He had returned from a holiday in Thailand ten days ago. On examination he was tall thin. There was clubbing lymphadenopathy. He was cyanosed. He had a resting tachycardia there was an audible click expiration. What is the likely diagnosis?

16

1

) Marfans' Syndrome

2 ) Mitral Valve Prolapse

3 ) Tzeize's syndrome

4 ) Pulmonary Embolism

5 ) Viral pericarditis

Comments:

Sudden onset chest pain breathlessness are likely due a PE pneumothorax. Hamman's Sign (or

'Crunch') a crunching systolic sound heard over sternal edge in mediastinal emphysema left apical pneumothoraces. It can be dependent on patients position when auscultating. 1 )

5. A 55 year male consulted his General Practitioner a three month history of lethargy

weight loss. Six years previously he was diagnosed diabetes mellitus was receiving Glibenclamide 10 mg daily Metformin 1g twice daily. On examination he was noted have a BMI of 25.6 kg/m2, a pulse of 88 beats per minute a

pressure of 164/102 mmHg. Fundal examination numerous dot haemorrhages in temporal retina of both eyes occasional hard exudates. Loss of position vibration sensation were

also noted

Investigations revealed:

mid tibia bilaterally.

Haemoglobin

14g/dL

White cell count

4.8

x 109/L

Platelets

195

x 109/L

Serum sodium

137

mmol/L

Serum potassium

4.6

mmol/L

Serum urea

16.7 mmol/L

Serum creatinine

220

umol/L

HbA1c

9.3%

Urinalysis

Protein++, Blood +

Which of the following is appropriate therapeutic strategy this patient?

1 ) Change Glibenclamide insulin

2 ) Maximise his current oral hypoglycaemic therapy

3 ) Rosiglitazone

4 ) Stop Metformin

5 ) Stop metformin Glibenclamide start insulin

Comments:

In this patient‟s case

nephropathy should be switched insulin. Most authorities recommended metformin should be

weight loss, modest BMI poor glycaemic control established retinopathy

stopped in patients a creatinine above 150 micromol/l although this

patients continue on metformin creatinines much higher than 150 without any ill effect. Although Rosiglitazone could be added either metformin glibenclamide, there would be little benefit gained in this manoeuvre as his problem now appears be weight loss osmotic

universal policy many

17

symptoms suggesting insulinopaenia. Similarly there would be little benefit in maximising his oral hypoglycaemic agents which are already at reasonably top dose. 5 )

6. A 22 year man, normally fit well, was referred hospital by his GP. His only

symptoms were of blurred vision headache had present

further questioning patient also said at he had

breathing had worse on exertion. There was history of ankle swelling, but he fell over 3 days previously hurt his leg he had

unable go out of house since. There was history of chest pain.

On examination he had a regular pulse of 110/minute a pressure of 200/120 mmHg JVP of 5cm. His heart sounds were normal. Chest on auscultation fine basal crepations a respiratory rate of 22/minute a sighing pattern. He had oedema of his right leg side. His

abdomen was soft non tender

An urinary catheter was instered. He was found have a residual volume of 50 mls of dark urine. Urinalysis showed Blood+++ Protein++. Microscopy showed organisms, but scanty

hyaline casts fewer than 10 red cells per high powered field.Investigations revealed:

preceeding two days. On

passing much urine

he had noticed his

masses. Fundoscopy was normal.

Serum sodium

135mmol/l

Serum potassium

7.4mmol/l

Serum urea

19.5 mmol/l

Serum creatinine

1044 mmol/l

Serum calcium

2.0

mmol/l

Serum phosphate

2.6

mmol/l

Bicarbonate

17 mmol/l

What treatment should he receive immediately?

1 ) Intravenous fluids

2 ) Intravenous insulin + dextrose + salbutamol

3 ) Intravenous sodium bicarbonate

4 ) Oral calcium resonium

5 ) Dialysis

Comments:

This man Rhabdomyolysis immediate treatment correction of his Potassium then correction of fluid balance acidosis. IV insulin Dextrose number one thereafter if urine output cannot be improved Potassium remains elevated. Dialysis maybe necessary. 2 )

7. A 58 year male was reviewed by his General Practitioner a three month history of

lethargy weight loss. He had a 10 year history of type 2 diabetes which he was treated Glibenclamide 10 mg daily Metformin 1g twice daily. He was receiving amlodipine 10mg daily as treatment his hypertension. He confessed poor compliance diet, he smoked 5 cigarettes daily drank approximately 12 units of alcohol weekly. On examination he was noted have a BMI of 25.6 kg/m2, a pulse of 88 beats per minute a pressure of 164/102 mmHg. Fundal examination dot haemorrhages in temporal retina of both eyes occasional hard exudates. Loss of position vibration sensation were also noted mid tibia bilaterally. Peripheral pulses were all preserved. Investigations revealed:

Haemoglobin

14g/dL

White cell count

4.8 x 109/L</TD

Platelets

195 x 109/L

18

Serum sodium

137

mmol/L

 

Serum potassium

4.6 mmol/L

 

Serum urea

16.7 mmol/L

 

Serum creatinine

220

umol/L

 

HbA1c

9.3%

(NR < 6%)

Urinalysis

Protein ++ Blood +

 

Which of the following is appropriate treatment for this patient’s blood pressure?

1 ) ACE inhibitor (+Frusemide) keep BP < 160/80

2 ) ACE inhibitor (+Frusemide) keep BP < 140/80

3 ) Increase antihypertensives (but exclude ACE) keep BP < 160/80

4 ) Increase antihypertensives (but exclude ACE) keep BP < 140/80

5 ) Lifestyle advice

Comments:

This patient appears have an established nephropathy ++ protein on urinalysis poor hypertensive control. Without appropriate investigation it difficult know whether creatinine of

220 due renal artery stenosis. He requires investigation of protein in urine, but in first

instance patient needs urgent control of his pressure. Target BP hypertensive patients should be less than 140/80, as described in Joint Guidelines lower in patient‟s established renal disease. Frusemide recognized as part of armoury in treatment of hypertension whereas Thiazide diuretics are. 4 )

8. A 48 year man adult Polycystic Kidney disease who on maintenance Haemodialysis

called Transplantation. He had his usual dialysis on evening before. On examination he a JVP of 3cm, BP 140/85 a clear chest on auscultation. His weight 1kg above Dry Weight. Investigations show:

Serum sodium

138 mmol/L

Serum potassium

5.5 mmol/L

Serum bicarbonate

19 mmol/L

Electrocardiogram

Normal

The transplant a good match surgery planned later on day. What treatment should he receive prior theatre?

1 ) Intravenous fluids

2 ) Intravenous insulin + dextrose +/ salbutamol

3 ) Intravenous sodium bicarbonate

4 ) Oral calcium resonium

5 ) Two hours of hemodialysis

Comments:

Haemodialysis will correct his acid base electrolyte disturbance. 5 )

9. A 52 year old man comes

complains of hearing strange noises occasionally non threatening voices. His wife says he also hears ‘music’. On more detailed questioning, he admits becoming more withdrawn

recently would spent of his time now ‘doing nothing’. His sleep poor he commonly wakes up at 2 3 a.m. in mornings. His appetite fallen off he eating very little, consequently losing about 10 kg in last three months. He admits drinking one a half bottles of whisky a day.

outpatient clinic his wife. Over last two months, he

19

During conversation, he appears calm, his speech clear articulate, but his attention poor. He tremor. His three minute recall of a given address impaired. He does exhibit any clouding of consciousness there suggestion of delusions paranoid symptoms. What is the likely diagnosis in this man?

1 ) Alcoholic hallucinosis

2 ) Korsakoff‟s psychosis

3 ) Major depression psychosis

4 ) Psychotic depression

5 ) Schizophrenia

Comments:

The presentation suggestive of major depression because of psychomotor retardation. Typical vegetative symptoms include anorexia, weight loss insomnia, particularly early morning awakening. Psychotic symptoms such as delusions hallucinations may occur in depression, when they do, treatment both an antidepressant an antipsychotic indicated. In alcohol induced psychotic disorder hallucinations, patient may have auditory hallucinations, usually voices. The

voices are characteristically maligning, reproachful threatening. The hallucinations usually last less than a week. After episode, patients realise hallucinatory nature of symptoms. Korsakoff‟s psychosis characterised by both anterograde retrograde amnesia, confabulation early in course. In psychotic depression, depression of psychotic intensity delusional convictions of disease, putrefaction poverty, contaminating others causing evil. There may also be hallucinations, typically accusing derogatory voices. Core symptoms of schizophrenia are delusions, hallucinations, disorganised speech, negative symptoms (e.g. blunted affect poverty of speech) disorganised behaviour. 3 )

10. A 55 year old man presents left loin pain. His pain radiates

groin from his left loin

severe in nature coming in spasms. He previously had a resection of small bowel a jejunocolic anastomosis Crohn’s disease. Prior admission he had eating well a diet, high in fibre usually drinks 3 litres of fluid per day. His Crohn’s disease had quiescent last twelve months on steriods. His bowel habit was him two loose stools per day. On examination his pressure 180/70 mmHg. His abdomen soft, but he tender in left loin.Investigations show:

Urinalysis

Blood +++, protein, nitrates

Urine pH

5.5

A plain abdominal kidney/ureter/bladder (KUB) x ray shows a radio opaque area over left ureter. An intravenous urogram (IVU) confirmed presence of a small calculi. What is the likely cause of his renal stone?

1 ) Calcium

2 ) Cysteine

3 ) Oxalate

4 ) Urate

5 ) Xanthine

Comments:

Oxalate stones are uncommon in dietary excess of oxalate. However enteric oxaluria may occur in a number of disorders in which malabsorption results in excessive colonic absorption of oxalate. These include coeliac disease, Crohn‟s disease, chronic pancreatitis short bowel syndrome. High fluid intake calcium carbonate are mainstay of prevention. 3 )

11. A 62 year male referred impotence. He was diagnosed diabetes mellitus 10 years

ago was initially treated diet but required metformin over last three years. Five years

20

previosuly he underwent a left hip replacement. Over last two years he

deteriorating erectile dysfunction

change in body hair. He a non smoker drinks approximately ten units of alcohol weekly. Examination reveals an obese male a pressure of 146/88 mmHg. And secondary sexual characteristics. Testicular examination reveals testes of approximately 15 mls in volume. There are abnormalities on cardiovascular, respiratory abdominal examinations. Investigations reveal:

aware of aware of any

now totally impotent. He shaves daily

Haemoglobin %

14.2 g/dL

   

White cell count

9.0

x 109/L

 

Platelets

188

x 109/L

 

Serum sodium

145

mmol/L

 

Serum potassium

4.5

mmol/L

 

Serum urea

7.2

mmol/L

 

Serum creatinine

110

µmol/L

 

Serum alkaline phosphatase

 

88

IU/L

(NR 50 120)

Serum aspartate aminotransferase

40

IU/L

(NR 20 50)

Serum gamma GT

42

(NR 10 50)

HbA1c

7.8

%

 

Fasting plasma glucose

7.8

mmol/L

 

Plasma testosterone

7.1

nmol/L

(NR 9.8 33)

Plasma FSH

4.1

mU/L

(NR 3 12)

Plasma luteinizing hormone

 

5.1

(NR 3 10)

Which of following would you select as further investigation of this patient?

1 ) Ferritin

2 ) MRI scan head

3 ) Oestradiol concentration

4 ) Prolactin concentration

5 ) Ultrasound testes

Comments:

This patient Hypogonadotrophic hypogonadism (HH)

LH/FSH low testosterone concentrations.

HH a relatively common scenario associated type 2 diabetes. The exact mechanism responsible

unknown. Haemochromatosis seems unlikely in absence of suggestive symptoms signs (arthritis, pigmentation, hepatomegaly, deranged LFTs). Hyperprolactinaemia may be associated a HH signs such as galactorrhoea may be present. However, as it appears

pituitary/hypothalamic axis

would be best imaging technique.2)

functioning properly it may be worth radiological imaging MRI

12. A 45 year lady Chronic Renal failure secondary Systemic Lupus Erythromatosis

seen in a low clearance clinic as a routine follow up. Her Joints have causing some

discomfort she

50mg od disease control. She stable renal function a Creatinine of 300mmol/l a

Creatinine clearance of 18ml/min. Associated her Chronic renal failure she controlled

secondary hyperparathyroidism. She

an OGD showed only mild gastritis. She already on oral ferrous sulphate 200mg tds 3 months.Investigations show:

taking Naproxen PRN as well as Prednisolone 2.5mg od Azathioprine

Anaemic

last 6 months investigation of dyspepsia

21

Haemoglobin%

9.4g/dL

 

hypochromic red cells

12%

 

Platelets

180 x 109/L

 

White cell count

6.4 x 109/L

 

Serum folate

4.0ug/L

(NR 2

11)

Serum ferritin

230ug/L

(NR 15 300)

Transferrin saturation

17%

 

What therapeutic intervention should now be considered?

1 ) Folate

2 ) GM CSF

3 ) Intravenous iron

4 ) Subcutaneous erythropoetin

5 ) Vitamin B12

Comments:

Intravenous iron first intervention as her percentage of hypochromic red cells 12% ferritin represents an acute phase protein. She responded oral iron. Epo would be a valid alternative

but only once iron deficiency corrected. You would check a B12 level but lots of Iron studies here."Iron also essential hemoglobin formation. The iron status of patient chronic Kidney Disease (CKD) must be assessed adequate iron stores. (National Kidney Foundation

guidelines)3)

13. A 27 year

referred by her GP. being 10 weeks pregnant. Three months ago she was

diagnosed thyrotoxicosis an elevated T4 concentration suppressed TSH concentration. At stage her GP started her on carbimazole. At presentation she a pulse of 90 beats per minute, a fine tremor lid lag. Blood pressure 118/80 mmHg she a palpable goitre. From following select appropriate treatment this patient?

1 ) Continue carbimazole

2 ) Radioactive iodine

3 ) Stop all drugs during pregnancy

4 ) Switch propylthiouracil

5 ) Thyroidectomy

Comments:

This patient thyrotoxicosis now pregnant. Thyrotoxicosis itself associated poor pregnancy outcome IUGR miscarriage. Therefore thyrotoxicosis needs be treated during pregnancy anti thyroid medication. The patient should be rendered euthyroid then this should be maintained on lowest dose of anti thyroid medication maintain euthyroidism. A block replacement regime contra indicated as both carbimazole propylthiouracil cross placenta far better than Thyroxine

so may induce fetal hypothyroidism. There little choose between carbimazole propylthiouracil. It was once considered carbimazole induced aplasia cutis in fetus but this more recently disputed as aplasia cutis may be an effect of thyrotoxicosis rather than a side effect of carbimazole. Consequently, patient should continue treatment Carbimazole. Radioactive iodine absolutely contra indicated in pregnancy. Any surgery should be reserved last resort in pregnancy as it associated increased risk of miscarriage. The pregnancy can progress without problems if thyrotoxicosis adequately treated. 1 )

14. A 20 year

student presents sleepiness, weakness vivid dreams which have

occurred over last two months.

22

She a six year history of type 1 diabetes

times daily Lyspro insulin evening long acting insulin

receiving twice daily insulin but had noted rather eratic control after she attended University. She generally adhered a good diet regularly monitored her BMs twice daily which tend be below 10. She receiving other treatment except insulin. She does smoke, lives in a flat two other student colleagues binge drinks often on Saturday nights.

Examination reveals a well

mmHg. No abnormalities are noted on examination.Investigations reveal:

using basal bolus insulin consisting of three

last six months. Prior

she had

a BMI of 23 kg/m2, a pulse of 80 bpm a pressure of 112/70

Haemoglobin

15.2 g/dL

 

White cell count

6.8

x 109/L

 

Platelets

280

x 109/L

 

Serum sodium

146

mmol/L

 

Serum potassium

3.9

mmol/L

 

Serum urea

5.5

mmol/L

 

Serum creatinine

88 umol/L

 

Plasma glucose

7.9

mmol/L

 

HbA1c

6.2%

(NR < 6%)

What is the likely explanation of her symptoms?

1 ) Hypoglycaemic episodes

2 ) Narcolepsy syndrome

3 ) Schizophrenia

4 ) Sleep apnoea

5 ) Temporal lobe epilepsy

Comments:

Seizures at night are associated sleep disruption deprivation of REM sleep, are thus generally associated vivid dreams. Narcolepsy associated hypersomnolence, cataplexy, sleep paralysis hypnagogic hallucinations classically associated vivid dreams. Sleep apnoea associated vivid dreams, but would be very unlikely in a young, non obese female. Schizophrenia an unlikely cause of this symptom. The likely cause of this symptom of vivid dreams in this patient nocturnal hypoglycaemia. REM sleep disruption may lead daytime weakness somnolence. 1 )

15. A 38 year old man presents an episode of right sided weakness affecting his right

arm leg. The weakness occurred while he was eating breakfast resolved completely in 30 minutes. Three months earlier he an episode of slurred speech lasting a few minutes had being investigated extensively in hospital. Aspirin 75 mg had started as treatment. On examination, he overweight a BMI of 38, pulse 88 beats/min regular BP 140/85 mmHg. Heart sounds are carotid bruits are detectable. The neurological examination unremarkable except an upgoing plantar response on right side. A Doppler ultrasound of carotid arteries reveal 50% stenosis in proximal carotid arteries bilaterally.What evidence based intervention is likely to prevent further episodes of patient’s condition?

1 ) Add clopidogrel aspirin

2 ) Add dipyridamole aspirin

3 ) Increase dose of aspirin 150mg daily

4 ) Stop aspirin start clopidogrel alone

5 ) Stop aspirin start dipyridamole alone

23

Comments:

This patient having recurrent episodes of anterior circulation transient ischaemic attacks (TIAs) despite being on aspirin. If aspirin alone ineffective in preventing TIAs, then a combination of

low dose aspirin dipyridamole modified release recommended. There

evaluating use of clopidogrel as add on therapy aspirin in cerebrovascular disease, although

clopidogrel

an appropriate alternative patients a contraindication aspirin. 2 )

trial data as yet

extensively evaluated in cardiovascular disease. However, clopidogrel

shown be

16. A 29 year old woman was referred

intake by her General Practitioner because of

appearance of a rash on her legs. Ten days previously she had seen her GP complaining of

a sore throat had given a seven day course of amoxicillin.

On examination she appeared well. She was febrile (38oC), pulse 90 beats per minute in

sinus rhythm

of both thighs, extending down

Urinalysis showed protein (+)

pressure 135/80 mmHg. Palpable purpura were seen on her buttocks

ankles. (+). What is the likely cause of her purpura?

back

1 ) Allergy amoxicillin

2 ) Epstein Barr virus infection

3 ) Group A Streptococcus infection

4 ) Infective endocarditis

5 ) Meningococcal septicaemia

Comments:

The description of rash its distribution highly suggestive of Henoch Schonlein purpura (HSP). The presence of protein onurine dipstick testing suggests co existing nephritis. The likely precipitant a Group A Streptococcal infection caused sore throat ten days earlier. The main initial concern would be exclude meningococcal septicaemia. The patient had this illness several days does appear be critically ill. Overwhelming infection DIC therefore unlikely.

There are insufficient features be able diagnose infective endocarditis. EBV infection associated a rash if ampicillin administered; rash this phenomenon typically maculopapular vasculitic. Allergic reactions penicillins usually manifest as a maculopapular rash vasculitis. Allergy does explain haematuria proteinuria. 3 )

17. A 42 year old widow presents a one week history of progressive confusion unsteady

gait. She works as a barmaid lives in poor social circumstances. On examination she malnourished disorientated. She nystagmus unable abduct either eye. The pupils are sluggish unequal. Ankle jerks are absent but upper limb reflexes are present. Shortly after her admission you are called ward as she become very drowsy collapsed on floor.

Investigations on admission were as follows:

Haemoglobin

11.4 g/dL

MCV

99

fL

White count

5.6

x 109/L

Platelets

230

x 109/L

Serum sodium

129

mmol/L

Serum potassium

3.2

mmol/L

Serum bilirubin

27

umol/L

24

Serum gamma GT

440

IU/L

 

Serum alkaline phosphatase

180

IU/L

 

Serum AST

90

IU/L

 

Serum ALT

45

IU/L

 

Serum albumin

33

g/L

 

Prothrombin time

12

sec

(Control 11.5 15.5 sec)

What was

likely cause of her presentation drowsiness?

1 ) Hyponatraemia

2 ) Brain stem CVA

3 ) Central pontine myelinolysis

4 ) Liver failure

5 ) Wernicke‟s encephalopathy

Comments:

This lady presents

Lower limb neuropathy also a feature of WE. Her occupation, poor nutrition, social situation, results all suggest underlying alcoholism. The hyponatraemia mild unlikely cause symptoms

CPM (related

over 2 weeks. Liver function appears well preserved (normal PT reasonable Albumin). 5 )

classic triad of WE (encephalopathy, gait ataxia occulomotor dysfunction).

gradual onset

rapid correction of Na+) unlikely. A brainstem CVA unlikely due

18. A 45 year old woman attends outpatient clinic follow up of her multiple sclerosis.

During conversation, she asks your advice on fluoxetine which she taking her depression.

She concerned about newspaper reports linking fluoxetine suicidal ideation

keen discontinue drug. On further questioning, you establish she a long history of depression. Initially her depression was severe but since starting on fluoxetine 20 mg daily, her symptoms have dramatically improved. She does have regular follow up psychiatrists feels her GP does take her concern seriously. What would you do her treatment?

therefore

1 ) Change another class of antidepressant

2 ) Reassure her continue fluoxetine

3 ) Reduce dose of fluoxetine

4 ) Refer her a psychiatrist

5 ) Stop fluoxetine altogether

Comments:

You should explain

established. Therefore it would be unwise stop fluoxetine altogether. Reassure her since her

depression well controlled by fluoxetine, she should continue it she likely relapse. In

addition, you should point out her

have fewer antimuscarinic side effects than older tricyclics. Also bear in mind SSRIs are less cardiotoxic than tricyclics in overdose. Apart from that, SSRIs are better than monoamine oxidase inhibitors (MAOIs) because they are more effective do show dangerous interactions some foods have fewer dangerous interactions drugs are characteristic of traditional MAOIs.2 )

patient although suicidal ideation

linked fluoxetine, causality

selective serotonin reuptake inhibitors (SSRIs) as a group

25

19.

A 45 year old labourer referred a three month history of tingling paraesthesiae of

left hand. On two occasions he dropped his cup of tea but put these down a bit of

clumsiness. His symptoms tend be more noticeable in evenings when he resting watching TV. He denies any muscle twitching. Bladder bowel function are reported as

normal. Past history unremarkable he

he often

n examination, he

appears in all muscle groups. Apart from an absent triceps reflex on left, his reflexes are all present symmetrical. Sensory examination reveals loss of pinprick sensation on palmar aspect of index, middle ring fingers of left hand. Tapping of palmar aspect of wrist fails elicit any tingling sensations in hand distally. Joint position sense vibration sense are both normal. Cranial nerve examination unremarkable. What is the likely diagnosis?

involved in any accidents recently. His job means

use vibrating tools do heavy manual lifting.

obvious loss of muscle bulk in his upper limbs. Tone normal. Power

1

) C7 root neuropathy

2

) Carpal tunnel syndrome

3

) Erb‟s palsy

4

) Klumpke‟s palsy

5

) Medial cord lesion

Comments:

The sensory disturbance in C7 dermatome absent triceps reflex (C7, C8) makes a C7 root neuropathy best answer. In carpal tunnel syndrome, sensory disturbance involves thumb, index, middle fingers lateral half of ring finger, triceps reflex will be affected. Erb‟s palsy usually result of traumatic avulsion of C5 C6 roots (commonly occurring during delivery at birth) causes loss of shoulder abduction elbow flexion loss of biceps brachioradialis reflexes. Klumpke‟s palsy, often result of a fall stopped by grasping a fixed object one hand, involves C8 T1 roots causes weakness of small muscles of hand of long finger flexors extensors, a

sensory disturbance affecting medial half of ring finger little finger. A medial cord lesion also affects C8 T1 roots. 1 )

20. 48 year teacher admitted a two day history of increasing breathlessness cough

productive of purulent sputum. He smoked 20 cigarettes a day since age of eighteen. He in hospital before but was recently diagnosed as having chronic obstructive pulmonary disease by his general practitioner. He taking an inhaled agonist on an as required basis.

On examination he breathless at rest, alert orientated. He cyanosed a respiratory rate of 26 breaths per minute. His temperature 37.8 C. His pulse 100/minute pressure 150/100. Auscultation of his chest reveals bilaterally reduced air entry. His chest radiograph demonstrates a heart size but lung fields are hyperinflated. There pneumonic consolidation. Arterial gases on admission on 24% oxygen by nasal cannulae show:

pH

7.34

 

pO2

6.5

kPa

pCO2

6.8

kPa

Standard bicarbonate

27

kPa

He treated nebulised bronchodilators his FIO2 increased 28%. The results of arterial gases repeated after 30 minutes are:

26

pH

7.30

 

pO2

7.0

kPa

pCO2

8.5

kPa

Standard bicarbonate

28

kPa

What further management is required

1 ) Reduce FiO2 24%

2 ) Intubation mechanical ventilation

3 ) Non invasive positive pressure ventilation (NIPPV/NIV)

4 ) Continuous positive pressure ventilation (CPAP)

now?

5 ) Give oxygen by face mask

Comments:

This patients ABG are deteriorating he developing an increasingly severe respiratory acidosis. He still alert haemodynamically stable therefore NIV (such as BiPAP) treatment of choice should be instigated without delay. 3 )

21. A 54 year sales representative was referred by his general practitioner complaining

of feeling tired all time. He had a history of depression which he was taking anti depressant tablets prescribed by GP. He had recently resigned from his job as he was too tired do large amount of driving required had nearly involved in a car accident when his car had swerved across road apparent reason. He was overweight admitted 3 stone increase in weight over last three years. His pressure was elevated at 170/100.What is the likely diagnosis?

1 ) Obstructive Sleep Apnoea Syndrome

2 ) Chronic Hyperventilation Syndrome

3 ) Hypothyroidism

4 ) Absence Seizures

5 ) Infectious Mononucleosis

Comments:

Obstructive sleep Apnoea (or Sleep Apnoea/Hypopnoea) Syndrome occurs when episodes of partial complete obstruction of pharyngeal airway occurs during sleep. This causes (a) repetative apnoeas (cessation of airflow > 10seconds) hypopnoeas (50% reduction in airflow greater than 10 seconds) (b) loud snoring (c) excessive daytime somnolence as a result of repeated arousals. The gold standard diagnostic test overnight polysomnography. Increasingly though simpler sleep monitoring systems simple overnight oximetry are being used often studies undertaken in patients home. The treatment of choice weight loss, avoid sedatives drugs/excess alcohol nasal CPAP. 1 )

22. A 23 year old woman presents complaining of a 'droopy face' occurring over last 24

hours. Two weeks previously she had several days of headache mild photophobia. The headache was of acute onset moderately severe. Over last week she also noticed mild

lower back discomfort occasional tingling in feet which she put down

'pulled a muscle' when walking.Two months ago she had returned from a holiday in

Thailand.

fact she had

27

She takes oral contraceptive pill. She smokes 20 cigarettes a day consumes alcohol socially. She a family history of migraine her mother died of a 'brain haemorrhage'.

On examination, she looks well. Pulse 88 beats/min, BP 105/75 mmHg, temperature 37°C.

On examination of her eyes, she

Fundoscopy unremarkable. Corneal reflexes are present equally on both sides. She difficulty closing her left eye it rolls it upwards in attempt. When cheeks are puffed, left side balloons more than right. The reset of cranial nerve examination unremarkable. Power symmetrical in upper lower limbs tone appears normal. She absent reflexes throughout, even reinforcement. Plantar responses are downgoing bilaterally. She able do finger to nose heel to shin testing adequately. Sensory examination of light touch, pinprick vibration sense are all normal.What is the likely diagnosis?

pupillary responses light a full range of eye movements.

1 ) Cerebrovascular infarction

2 ) Guillain Barre syndrome

3 ) Migraine

4 ) Multiple sclerosis

5 ) Ruptured berry aneurysm

Comments:

The history of lower back pain, subjective sensory symptoms in absence of objective signs, left lower motor neurone facial palsy absent reflexes make Guillain Barre syndrome likely diagnosis. The time delay between onset of facial weakness initial headache makes diagnosis of a subarachnoid haemorrhage, cerebrovascular infarction migraine extremely unlikely. To make a clinical diagnisis of multiple sclerosis, we will need two separate symptoms at two separate times lesions disseminated in space in time if other problem can be found explain patient's condition conditions which patient does fulfill. 2 )

23. A 22 year old obese man presents mild ankle oedema urinalysis shows protein +++

blood. A diagnosis of Nephrotic Syndrome made on basis of a cholesterol of 6.9, an albumin of 30g/dl proteinuria of 8g/24hours. He ankle oedema a BP of 145/90. A renal biopsy arranged following week. A protein selectivity index of 15% found on analysis of his urine. He empirically started on prednisolone 60mg daily. His 24 hour urine collection repeated prior renal biopsy this shows a reduction in his urine protein output 1.5g/24 hours.What is the likely diagnosis?

1 ) Amyloid

2 ) Focal Segmental Glomerulosclerosis

3 ) Membranoproliferative Glomerulonephritis

4 ) Membranous Nephropathy

5 ) Minimal Change Nephropathy

Comments:

In this age group

near 100% in Minimal Change but only about 40% in FSGS. A protein selectivity index of <10%

highly selective

disease but less reliable in adults. 5 )

24. A 70 year old man referred a six month history of increasing unsteadiness. He an

irregular swaying gait a tendency drift

keep his feet apart when standing. In addition he noticed problems urinary urgency

haematuria, minimal change nephropathy

likely. Steriod responsiveness

a ratio of serum urine IgG albumin. High selectivity suggests Minimal Change

right when walking. His wife comments he tends

28

frequency. Multiple urine samples sent by his GP have failed detect infection. His muscles

sometimes feel stiff but he puts this down

On examination, pulse 72 beats/min, BP 140/85 mmHg lying, 110/60 mmHg standing.The muscles of upper lower limbs show increase tone in opposing muscle groups when

age.

joints are passively moved. There

obvious loss of muscle bulk. Power appears be in all

muscle groups. Gait broad based a tendency lean

plantar responses were downgoing bilaterally. Finger to nose testing impaired in upper

limbs. Sensory examination unremarkable.

What is the likely diagnosis?

right. Reflexes were brisk throughout

1 ) Amyotrophic lateral sclerosis

2 ) Chronic inflammatory demyelinating polyneuropathy 3 ) Freidreich‟s ataxia

4 ) Multiple system atrophy

5 ) Polymyositis

Comments:

Multiple system atrophy a degenerative disorder characterised by parkinsonian features, autonomic insufficiency (leading postural hypotension, anhidrosis, disturbance of sphincter control, impotence) signs of a cerebellar deficit. Chronic inflammatory demyelinating polyneuropathy clinically similar Guillain Barre syndrome (hyporeflexia areflexia, paraesthesiae

mild sensory deficits in upper lower extremities, weakness) except it follows a chronic progressive course. Friedreich‟s ataxia characterised by progressive gait ataxia, depressed knee ankle reflexes, cerebellar signs, impairment of joint position vibration sense clinical manifestations almost always begin appear before puberty. Polymyositis often presents muscle weakness wasting, especially of proximal girdle muscles, muscle pain tenderness, weight loss a low grade fever. 4 )

25. A 56 year male a 12 year history of diabetes mellitus presents annual review. He

currently receiving gliclazide at a dose of 80 mg twice daily. Examination reveals a pulse of

76 beats per minute regular a pressure of 152/90 mmHg. Fundal examination reveals bilateral dot haemorrhages scattered hard exudates. He loss of vibration sensation in ankles but all pulses are palpable. Investigations reveal:

Serum sodium

138

mmol/L

Serum potassium

3.8

mmol/L

Serum urea

10.2

mmol/L

Serum creatinine

160

µmol/L

Glucose

12.1

mmol/L

HbA1c

9.5%

Cholesterol

5.5

mmol/L

Triglycerides

2.8

mmol/L

Which of following measures would you adopt improve this patient's prognosis?

1 ) ACE inhibitor

2 ) Beta blocker

3 ) Increased dose of gliclazide

4 ) Insulin

29

5

) None

Comments:

This patient microvascular complications related his diabetes particularly Nephropathy, Neuropathy Retinopathy. However, subjects type 2 diabetes have a 2 4 fold increased cardiovascular mortality from which this patient probably prone in view of his established chronic renal impairment. Studies such as UKPDS reveal improving glycaemic control would reduce microvascular complications but this significant impact upon cardiovascular morbidity mortality. However, lowering pressure significantly reduced morbidity from both microvascular macrovascular disease. In this study ACEI compared beta blockers results were similar. But, HOPE study (using Ramipril) suggested mortality in patients at risk of cardiovascular disease (inc diabetics) may be further reduced by addition of an ACEI their standard regime. ACEI may have a superior efficacy in delaying progression of nephropathy. 1 )

26. A 48 year lady presents increasing breathlessness cough. This

last year she had repeated chest infections over last six months. She smoked 10

cigarettes a day until eight years ago. She chest x ray was reported as being normal. Pulmonary function testing demonstrated:

getting worse over

known allergies. She works as a hairdresser. A

FEV1

1.60

L

(53% predicted)

FVC

2.86

L

(78% predicted)

Total lung capacity

4.83

L

(110% predicted)

TLCO

6.63%

(93% predicted)

KCO

1.36

(120% predicted)

What is the likely diagnosis?

1 ) Emphysema

2 ) Chronic Bronchitis

3 ) Asthma

4 ) Pulmonary Embolism

5 ) Obesity

Comments:

This lady moderate airways obstruction: FEV1/FVC = 56% predicted. Transfer factor transfer co efficient can be elevated in patients asthma but always reduced in emphysema. Patients extra pulmonary restrictive defects such as morbidity show an elevated Kco Tlco but restrictive

defect produces a

27. A 40 year old woman referred you complaining of a three month history of

dizziness a ‘ringing noise’ in her left ear. The dizziness intermittent in nature usually

lasts up two minutes. She noise in her ear as being having a regular rhythm. Over last two weeks, she also noticed mild difficulty closing her left eyelid her friends have commented her face slightly asymmetrical.

On examination, she looks relatively anxious. Cranial nerve examination reveals a mild difficulty in closing eyelid of her left eye. She also a slight droop over left side of her face when she asked smile. Hallpike’s manoeuvre negative. Weber’s test reveals lateralisation of sound left ear. Rinne’s test reveals bone conduction better than air conduction in left ear vice versa in right ear. Testing of gag reflex reveals reduced a sensation on left side. The rest of neurological examination unremarkable.

Where

elevated FEV1/FVC

reduced lung volumes. 3 )

site of this patient’s lesion?

30

1

) Cerebellopontine angle

2 ) Glomus jugulare

3 ) Internal capsule

4 ) Midbrain

5 ) Pons

Comments:

Cranial nerves IX, X XI run through jugular foramen. Therefore a glomus jugulare tumour

affects one, two all three of these cranial nerves. The tumour can enlarge sufficiently damage cranial nerves VII XII. The clue this question lies in clinical features of a pulsatile tinnitus (suggested by regular rhythmic „ringing noise) ipsilateral conductive deafness. Glomus jugulare tumour a highly vascular tumour which will account pulsatile tinnitus. The conductive deafness can be accounted by fact tumour commonly presents as a mass behind tympanic membrane. Most nonfamilial tumours have a preponderance an onset in fourth decade. The tumours may also occur in an autosomal dominant fashion. 2 )

28. A 56 year builder presents cough breathlessness. He known have chronic

obstructive pulmonary disease Ulcerative Colitis. He smokes up 20 cigarettes a day. The cough productive of clear sputum up 500ml a day. He had haemoptysis. The breathlessness now restricts his exercise tolerance 50 metres. He lost over 2 stone in 2 months. Examination dullness percussion at right lung base. His abdomen was generally tender but there was guarding. What is the likely diagnosis?

1 ) Bronchiolitis obliterans organizing pneumonia

2 ) Bronchioloalveolar cell carcinoma

3 ) Alveolar Proteinosis

4 ) Adenocarcinoma of lung

5 ) Bronchopleural fistula

Comments:

Bronchiolalveolar cell carcinoma of lung account around 5% of all primary lung carcinomas. The classic massive clear frothy sputum produced by patients this cancer a late manifestation but can be up one litre a day. Other symptoms are dyspnoea, weight loss chest pain. Almost a half of patients are diagnosed on routine CXR, usually demonstrating a peripheral lesion. Its name arises from its pattern of growth along alveolar walls without actually destroying them. It an adenocarcinoma. In those whose tumour resectable prognosis poor. 2 )

29. A 26 year diabetic patient presented

had a party but complained of sudden worsening of a three day history of increasing

breathlessness. The following results were obtained from an arterial gas sample. What your interpretation of these gas results?

accident emergency department at 2am. He

pH

7.66

pO2

7.4

pCO2

4.7

Standard bicarbonate

30

H+

21

1 ) Metabolic alkalosis

2 ) Respiratory alkalosis

3 ) Mixed metabolic respiratory alkalosis

4 ) Metabolic acidosis respiratory alkalosis

5 ) Laboratory error

31

Comments:

The patient severely alkalotic be a laboratory error. 5 )

30. A 52 year old presents weight loss, anxiety difficulty sleeping. She had taking

combined cyclical oestrogen/progesterone hormone replacement therapy over last two years. On examination she was noted have a body mass index of 26.5 kg/m2, a pulse of 104 beats per minute a pressure of 112/72 mmHg. No goitre was palpable eye movements were entirely normal. She was noted have weakness of proximal musculature of shoulder hip girdles. Initial investigations revealed:

a bicarbonate. He a pCO2

hypoxic. The only explanation must

Serum total thyroxine

250

nmol/L

(NR 60 140)

Plasma TSH

< 0.1 mu/L

(NR 0.4 4.0)

Serum alkaline phosphatase

202

IU/L

(NR 50 100)

Serum gamma glutamyl transferase

30

IU/L

(NR 10 50)

Her general practitioner commenced her on Carbimazole 10 mg tds together propranolol 120 mg bd. At review six weeks later patient appeared clinically euthyroid. Repeat investigations showed:

Total thyroxine

180

nmol/L

Plasma TSH

2.2 mU/L

Serum alkaline phosphatase

160

IU/L

Serum gamma glutamyl transferase

36

IU/L

The dose of carbimazole was decreased 20 mg daily. After 1 year GP decided refer her endocrine outpatients. Two weeks before she had a chest infection treated erythromycin. Her test results showed:

Serum total thyroxine

80

nmol/L

Plasma TSH

12.8 mU/L

Serum alkaline phosphatase

102 IU/L

Serum gamma glutamyl transferase

42

IU/L

What is the cause of her thyroid function test results at her outpatient visit?

1 ) Interaction between erythromycin carbimazole

2 ) Interaction between HRT carbimazole

3 ) Patient stopped HRT

4 ) Over treatment carbimazole

5 ) Recent chest infection

Comments:

This patient was hyperthyroid was treated carbimazole

now made her hypothyroid as reflected

by high TSH. Although her total thyroid hormone concentration

low. Although this might be due increased Thyroid Binding Globulin associated HRT, it more

likely

prescribed her URTI. 1 )

it likely her free T4 would be

effect of carbimazole

potentiated by liver enzyme inhibiting effect of erythromycin was

32

31.

A 45 year

presents depression, constipation, polyuria and thirst. Over last six

months she become increasingly aware of tiredness arthralgia since being diagnosed

hypertension

entirely except a pressure of 162/94 mmHg.

Investigations show:

treated bendrofluazide 2.5 mg daily. Physical examination proves be

Haemoglobin

14.4

g/dL

White cell count

7.1

x 109/L

Platelets

200

x 109/L

Serum sodium

148

mmol/L

Serum potassium

4.2

mmol/L

Serum chloride

105

mmol/L

Serum bicarbonate

28

mmol/L

Serum urea

8 mmol/L

Serum creatinine

105

umol/L

Serum corrected calcium

3.14

mmol/L

Serum bilirubin

16

umol/L

Serum alanine aminotransferase

10

IU/L

Serum aspartate aminotransferase

17

IU/L

Serum alkaline phosphatase

130

IU/L

Plasma parathyroid hormone

17

pmol/L

Which of the following is appropriate initial therapy?

1 ) Calcitonin

2 ) Frusemide

3 ) Intravenous saline

4 ) Pamidronate

5 ) Steroids

Comments:

This patient primary hyperparathyroidism

She dehydrated requires appropriate fluid replacement. Once corrected patient could then be

offered surgery as

effects tend be transient. Pamidronate effective at reducing calcium over a couple of days but it

important first ensure

hypercalcaemia sarcoid but ineffective in primary hyperparathyroidism. Frusemide often

used induce a hypercalciuria in severe hypercalcaemia once patient

32. A previously well 46 year old man presents a two day history of progressively

worsening headaches, dizziness, double vision, dry mouth swallowing difficulties. His wife

also noticed his face

gastrointestinal symptoms. Three days ago he injured his left hand while gardening

wound on his little finger red tender.

On examination, he alert orientated. Pulse 60 beats/min, BP 130/65 mmHg, temperature

38¢?C. He ptosis, large poorly reactive pupils, diplopia on looking

horizontally bilaterally, weakness of closing eyelids (right worse than left) inability whistle properly. He also chokes when asked swallow a little water. Power mildly

33

hypercalcaemia should initially be treated IV saline.

appropriate therapeutic option. Calcitonin reserved severe hypercalcaemia

patient adequately hydrated. Steroids are effective in certain types of

adequately rehydrated. 3 )

slightly asymmetrical over last day so. He denies any sensory

extremities

generally reduced in upper limbs lower limbs. Deep tendon reflexes are generally depressed sensation normal.Investigations reveal:

Haemoglobin

14.0

g/dL

White count

10.0

x 109/L

Platelets

200

x 109/L

Serum sodium

139

mmol/L

Serum potassium

4.0

mmol/L

Serum urea

6.8

mmol/L

Plasma glucose

7.5

mmol/L

CSF examination

Opening pressure

15 cm H2O

Cell count

< 2 per mm3

CSF protein

0.3

g/L

CSF glucose

6.1

mmol/L

What is the likely diagnosis?

1 ) Botulism

2 ) Guillain Barre syndrome

3 ) Lyme disease

4 ) Myasthenia gravis

5 ) Tetanus

Comments:

Botulism occurs either from gut colonisation (e.g. ingestion of contaminated home canned food) an infected wound. Clostridium botulinum spores are widespread in soil aquatic sediment. Typical initial features include diplopia, ptosis, facial weakness, dysarthria dysphagia. Later,

respiratory difficulty limb weakness occur. Neuromuscular blockade causes clinical features. In botulism, impaired cholinergic transmission also involves autonomic synapses, causing poorly reactive dilated pupils, dry mouth, paralytic ileus occasionally bradycardia. Reflexes are depressed absent, sensation CSF in botulism. In Miller Fisher variant of Guillain Barre syndrome, CSF often shows elevated protein. Lyme disease tends spare extraocular muscles.

Pupillary abnormalities do occur in myasthenis gravis. In tetanus, clinical features include jaw stiffness, spasm of jaw muscles hyperreflexia. 1 )

33. A 62 year male presents recurrent episodes of weakness of right arm numbness of

face. He was admitted one year ago a similar episode. He was diagnosed a transient ischaemic attack was commenced on aspirin 75mg daily. However, since this initial episode he had two further episodes. Examination reveals an obese subject a BMI of 38, a pulse of 76 beats per minute regular a pressure of 136/82 mmHg. Cardiovascular examination normal, all pulses are palpable he carotid bruit audible. Which evidence based intervention would be likely to prevent further episodes?

1 ) Aspirin plus clopidrogel

2 ) Aspirin plus dipyridamole

3 ) Increase dose of aspirin 150mg daily

34

4

) Switch clopidogrel alone

5 ) Switch dipyridamole alone

Comments:

The 2002 guidelines from Royal College of Physicians suggest

aspirin may have additive effects in reducing stroke based on ESPS 2 data. There little support

use of doses of aspirin greater than 75mg daily. 2 )

34. A 46 year old man admitted feeling generally unwell. He complains of increasing

stiffness in his arms jaws. He a mild throbbing frontal headache which he says typical of migraine from which he known suffer from. He also a history of schizophrenia last visited psychiatrist a month ago. Medications include sumatriptan fluphenazine, both of

which he

On examination, his pulse 90 beats/min, BP 180/85 mmHg temperature 38.5°C. Pulsatile temporal arteries are noted bilaterally. Neurological examination reveals mild generalized

increase in tone throughout but otherwise unremarkable. Investigations:

addition of dipyridamole

on approximately two years.

Hb

12.6 g/dl

WCC

4.9

x 109/l

Platelets

200

x 109/l

ESR

5 mm/hr

Plasma sodium

145

mmol/l

Plasma potassium

3.7

mmol/l

Plasma urea

4.9

mmol/l

Which of following drug treatments would you consider this patient's condition?

1 ) Benztropine

2 ) Bromocriptine

3 ) Lithium

4 ) Prednisolone

5 ) Procyclidine

Comments:

The diagnosis neuroleptic malignant syndrome (NMS), which can occur at any time during treatment of antipsychotic medications. Concomitant treatment lithium anticholinergics may increase risk of NMS. It manifested as by fever, rigidity, altered mental status autonomic dysfunction. Treatment includes withdrawal of offending agent, reduction of body temperature antipyretics. Dantrolene, bromocriptine levodopa preparations may be beneficial. Temporal

arteritis uncommon below age of 60. Benztropine, procyclidine lithium may all precipitate NMS. 2 )

35. A 26 year man presents haemoptysis. He had a productive cough since childhood suffered

from recurrent sinusitis. He was known be infertile. Investigations

sodium negative skin prick tests grass pollen, house dust mite aspergillus. What is the likely

diagnosis?

immunoglobulins, sweat

1 ) Bronchiectasis

2 ) Bronchiolitis

3 ) Cystic Fibrosis

4 ) Situs Inversus

5 ) Primary Ciliary Dyskinesia

35

Comments:

Primary Ciliary Dyskinesia a hereditary condition in which there partial complete deficiency of outer inner dynein arms of cilia causing slow poorly co ordinated ciliary beating throughout

body. Patients suffer from Bronchiectasis Sinusitis. They are infertile because of reduced motility of sperm. It associated in 50% of cases dextrocardia situs inversus when it called Kartagener's syndrome. Patients Cystic Fibrosis also have bronchiectasis sinusitis are infertile as vas deferens fails develop. Patients cystic fibrosis have an abnormal sweat test high levels of sodium chloride although care needs be taken interpreting test in adults. The diagnosis usually confirmed by determining patient's genotype. 5 )

36. A 68 year man dialysis via a haemodialysis line. He seen on renal unit complaining

of general malaise. He lost weight over last four months

Sometimes he joint aches back pain which mainly lumbar in origin. The back pain getting worse but does stop him mobilising. He had a course of Flucloxacillin an infection of his dialysis line 4 weeks ago which appeared clear infection.He dialysis three times

per week 4 hours per session

carbonate tablets Alucaps hyperphospataemia which now controlled. His aluminium

levels are

alphacalcidol. He

days. On examination he apyrexial

tender. PR was normal. He some lumbar spine tenderness. Investigations reveal:

sleeping well due sweats.

had recorded pyrexias. He takes a combination of calcium

his plasma parathyroid hormone level only mildly elevated having started 1

on erythropoietin six months receives intravenous iron on dialysis

heart sounds a clear chest

oedema. Abdomen soft non

Haemoglobin

7.8g/dL

MCV

86

fL

White cell count

8.0 x 109/L

Platelets

180 x 109/L

ESR (Westergren)

78

mm/1st hour

What is the likely cause of her unresponsiveness erythropoietin?

1 ) Aluminium toxicity

2 ) Septicemia

3 ) Under dialysed

4 ) Hyperparathyroidism

5 ) Occult gastrointestinal bleeding

Comments:

The likely explanation Sepsis secondary Osteomyelitis of lumbar spine. Hyperparathyroidism

unlikely be cause only a mildly elevated result. 2 )

37. A 54 year sales representative was referred by his general practitioner complaining

of feeling tired all time. He had a history of depression which he was taking anti depressant tablets prescribed by GP. He had recently resigned from his job as he was too

tired do large amount of driving required had nearly involved in a car accident when his

car had swerved across road

increase in weight over last three years. His pressure was elevated at 170/100.Which

investigation

apparent reason. He was overweight admitted 3 stone

likely provide correct diagnosis?

1 ) 24 hour monitoring

2 ) Overnight oximetry

3 ) TSH level

4 ) Paul Bunnell test

36

5

) EEG

Comments:

Obstructive sleep Apnoea (or Sleep Apnoea/Hypopnoea) Syndrome occurs when episodes of partial complete obstruction of pharyngeal airway occurs during sleep. This causes (a) repetative apnoeas (cessation of airflow > 10seconds) hypopnoeas (50% reduction in airflow greater than 10 seconds) (b) loud snoring (c) excessive daytime somnolence as a result of repeated arousals.

The gold standard diagnostic test overnight polysomnography. Increasingly though simpler sleep monitoring systems simple overnight oximetry are being used often studies undertaken in patients home. The treatment of choice weight loss, avoid sedatives drugs/excess alcohol nasal CPAP. 2 )

38. A 74 year old presents as an acute admission confusion diarrhoea. Little known of

her past history except it noted on GP letter she receiving treatment manic depression hypothyroidism.

Examination reveals she a Glasgow Coma Scale of 15 but confused. She thin, unkempt dehydrated a temperature of 370C. She a pulse of 82 beats per minute in a regular rhythm a pressure of 112/72 mmHg. She noted have a coarse tremor dysarthric speech.Which of the following is appropriate investigation assist in her management?