BACK TO THE OLD SCHOOL

QUESTION 1. A four week old male infant presents with difficulty feeding.

Mum is worried that he vomits (forcefully) after his feeds, and this is becoming more frequent. In addition, he is constantly hungry despite feeding well and has failed to gain any weight. Stools are normal. On examination a palpable 'olive' mass is felt in the right upper quadrant.

What is the most likely diagnosis?

(a)gastro-oesophageal reflux disease (b)duodenal atresia (c)pyloric stenosis (d)UTI (e)Intussusception

QUESTION 2

A 6 year old boy presents to you with a short history of abdominal and joint pain. He is otherwise well and apyrexic. You notice a non-blanching purpuric rash on his legs. What diagnosis would be your primary concern?

A Thrombocytopenic purpura B Henoch-Schonlein purpura C Erythema nodosum D SLE E Chronic urticaria

QUESTION 3

A 66 year old man with a 5 year history of hypertension was found to have a serum potassium level of 6.2 mmol/L on routine testing. This was confirmed on repeat testing. Which of his other medications are most likely to have contributed to his hyperkalaemia?

A Amlodipine B Aspirin C Bendroflumethazide D Perindopril E Pravastatin

QUESTION 4

A 64 year old man presented to OOH with a cough and shortness of breath. He was commenced on an unknown antibiotic and sent home. Three days later he attends his GP with increased skin pigmentation in the distribution shown.

A Amoxicillin B Cefaclor C Clarithromycin D Erythromycin E Levofloxacin

QUESTION 5 Which of the following statements regarding

anticoagulant therapy is correct?

A The anticoagulant effect of warfarin is enhanced by antibiotics.

B Heparin promotes thrombin synthesis. C A large first dose of warfarin produces a

rapid onset of anticoagulation effect. D Vitamin A deficiency impairs blood

coagulation and therefore enhances the action of warfarin.

E Warfarin is antagonized by salicylates.

QUESTION 6 A 27 year-old lady is distressed to learn that

she has had a miscarriage, with a 7 week non-viable pregnancy. This is her third in 4 years. On reviewing her notes you note a raised anti-cardiolipin antibody titre in her laboratory results section. What other clinical problem would fit with the diagnosis of anti-phospholipid syndrome?

A Pneumothorax B Arthritis C Photosensitive rash D Deep venous thrombosis E Polycystic ovaries

QUESTION 7

What is the diagnosis?

(a) Complete heart block

(b) Left bundle branch block

(c) Old infero-posterior infarct, and trifasciular block

(d) Acute posterior infarct

(e) 2nd degree heart block

QUESTION 8 A 65 year old man presents to you with fatigue and loss of

appetite. On examination: jaundice; palpable non-tender mass in the right upper quadrant.

The results of his liver function tests are below Albumin: 30 (35 - 50 g/L) ALK: 600 (39 - 117 U/L) ALT: 50 (5 - 40 U/L) Bilirubin: 80 (< 17 µmol/L) GGT: 220 (11 - 58 U/L) Urinalyis showed the presence of bilirubin. Urobilinogen was undetectable. Alpha feto-

protein was normal. What is the most likely diagnosis? (a) Pancreatic carcinoma (b) Hepatocellular carcinoma (c) Hepatitis (d) Haemolytic anaemia (e) Alcoholic liver disease

QUESTION 9 A 60 year old woman attends with a lump in her right

breast. The lump was noticed when she checked her breast after a fall on her chest. There is no nipple discharge. On examination there is a palpable fixed mass approximately 4cm x 3cm in the upper outer quadrant, with a smooth border. Mammogram showed a dense opacity. Histopathology ruled out breast cancer.

Which of the following is the most likely diagnosis?

A Duct papilloma B Fat necrosis C Duct ectasia D Fibroadenoma E Breast cyst

QUESTION 10 A 35 year old woman complains to you of a facial rash, with

purple discolouration of the eyelids and a swollen eye. She has also noticed some non-pruritic bluish/red nodules over her knuckles

What is the most likely diagnosis?

(a) Urticaria

(b) Dermatomyositis

(c) Lichen planus

(d) Pityriasis rosea

(e) Granuloma annulare

QUESTION 11 A 25 year old woman notices a red, painful

rash on her shins.

Which of the following would you consider as a cause?

(a) Inflammatory bowel disease

(b) Oral contraceptive pill

(c) Post-streptococcal infection

(d) Sarcoidosis

(e) All of the above

QUESTION 12

You auscultate a one year old child's precordium. You hear two heart sounds and a continuous grade 2 murmur sited below the left clavicle.

What is the most likely cardiac defect? A Ventricular septal defect (VSD) B Atrial septal defect (ASD) C Patent ductus arteriosus (PDA) D Transposition of the great vessels E Totally anomalous pulmonary venous

drainage

QUESTION 13 A five year old Asian boy presents with a two

week history of being "off-form" with fever and lethargy. His parents also state that the skin on his hands have started to peel.

What important condition would you think of?

A Viral Meningitis B IgA Nephropathy C Henoch Schönlein Purpura D Idiopathic thrombocytopenic purpura (ITP) E Kawasaki's disease

QUESTION 14

Which of the following signs are not associated with severe pulmonary hypertension?

A Hepatomegaly B Right ventricular heave C Large V waves in the JVP D Pan-systolic murmur loudest at the lower

left sternal edge in expiration E Peripheral oedema

QUESTION 15 A 42 year old man presented to his GP with troublesome

headaches mainly occurring at night. He describes them as excruciating, and during an attack his wife states that he becomes aggressive, noisy and has been known to kick furniture and walls. The headaches usually last about 60 minutes and occasionally his left eye becomes red and injected. It sometimes droops, making his wife think that he is having a stroke. He can sometimes have up to 6 attacks per night. Bad bouts occur every 3-4 months. He is well in between these episodes.

What is the diagnosis ? A Chronic migraine B Paroxysmal hemicrania C Short lasting unilateral neuralgiform headache with

conjunctival injection and tearing D Cluster headache E Herald bleeds

ANSWERS

QUESTION 1. A four week old male infant presents with difficulty feeding.

Mum is worried that he vomits (forcefully) after his feeds, and this is becoming more frequent. In addition, he is constantly hungry despite feeding well and has failed to gain any weight. Stools are normal. On examination a palpable 'olive' mass is felt in the right upper quadrant.

What is the most likely diagnosis? (a) gastro-oesophageal reflux disease

(b) duodenal atresia

(c)pyloric stenosis

(a) UTI

(b) Intussusception

All of the above diagnoses should be considered in an infant presenting with vomiting or regurgitation. However, the history above is consistent with pyloric stenosis.

Pyloric stenosis typically presents between 2 and 8 weeks of age. It is four times more common in males, particularly first borns, and may be associated with a family history. Classic features are:

Non-bilious projectile vomiting Constant hunger despite feeding Weight loss or poor weight gain A hypochloraemic metabolic alkalosis with low plasma

potassium (from vomiting stomach contents) Signs of dehydration (eg. decreased urine output, poor skin

turgor) Examination of the abdomen often reveals an 'olive' mass in

the RUQ. Clinical diagnosis may be made by using a test feed – the

baby is given a milk feed, and the abdomen examined: visible gastric peristalsis is seen as a wave moving left to right across the abdomen. If the abdomen is distended, this may be difficult to appreciate. Ultrasound is the primary imaging modality to confirm the diagnosis.

Treatment is initially with correction of fluid and electrolytes abnormalities followed by pyloromyotomy.

QUESTION 2

A 6 year old boy presents to you with a short history of abdominal and joint pain. He is otherwise well and apyrexic. You notice a non-blanching purpuric rash on his legs. What diagnosis would be your primary concern?

A Thrombocytopenic purpura

B Henoch-Schonlein purpura

C Erythema nodosum D SLE E Chronic urticaria

Henoch-Schonlein purpura (HSP) usually occurs between the ages of 3 and 10 years. It is more common in males, has a peak in winter, and is often preceded by a URTI. The characteristic features include: Symmetrical purpuric rash, commonly over the buttocks and extensor surfaces of arms and legs, with sparing of the trunk. Arthralgia Periarticular oedema Colicky abdominal pain Over 80% of patients with HSP have either microscopic or macroscopic haematuria or mild proteinuria at presentation. The disease is usually self-limiting, but nephrotic syndrome is a rare complication.

QUESTION 3

A 66 year old man with a 5 year history of hypertension was found to have a serum potassium level of 6.2 mmol/L on routine testing. This was confirmed on repeat testing. Which of his other medications are most likely to have contributed to his hyperkalaemia?

A Amlodipine B Aspirin C Bendroflumethazide

D Perindopril

E Pravastatin

Typical drugs that induce hyperkalaemia are:

ACE inhibitors (such as perindopril), Angiotensin receptor blockers, Potassium supplements (eg, Slow-K), Potassium-sparing diuretics (eg, spironolactone), Trimethoprim.

Amlodipine as a non-dihydropyridine calcium channel blocker, may contribute to hyperglycaemia but has no effect on serum potassium. Aspirin may sometimes cause thrombocytopenia, but has no effect on serum potassium. Bendroflumethazide as a thiazide may contribute to hypercalcaemia, hyperuricaemia and hyperglycaemia, but will lower serum potassium and sodium. Pravastatin as a HMG CoA reductase inhibitor (statin), may cause elevation of liver enzymes or of creatine kinase (CK) in susceptible individuals, but has no effect on serum potassium.

QUESTION 4

A 64 year old man presented to OOH with a cough and shortness of breath. He was commenced on an unknown antibiotic and sent home. Three days later he attends his GP with increased skin pigmentation in the distribution shown.

A Amoxicillin B Cefaclor C Clarithromycin

D Erythromycin

E Levofloxacin

Photosensitive eruptions are confined to areas exposed to light. They spare the triangle behind the ear, the upper eyelid, and areas under the nose, the chin, the watchband, and ring

Quinolones (except moxifloxacin) and tetracyclines are the most common classes of antimicrobials associated with photosensitive drug eruptions. Ceftazidime and cefuroxime may result in a photosensitive reaction but it is uncommon to cephalosporins and not described with cefaclor. Penicillins and macrolides (except azithromycin) are not usually associated with this kind of reaction.

QUESTION 5

Which of the following statements regarding anticoagulant therapy is correct?

A The anticoagulant effect of warfarin is enhanced by antibiotics.

B Heparin promotes thrombin synthesis. C A large first dose of warfarin produces a rapid onset of

anticoagulation effect. D Vitamin A deficiency impairs blood coagulation and therefore

enhances the action of warfarin. E Warfarin is antagonized by salicylates.

Antibiotics (e.g. tetracyclines) may reduce the vitamin K-synthesising bacteria in the gut and so decrease the availability of vitamin K for the hepatic formation of the vitamin K dependent clotting

factors: II, VII, IX and X, thus enhancing the anticoagulant effect of warfarin. Heparin acts at a large number of sites accelerating the neutralization of factors IXa, Xa, XIIa and

promotes the inhibition of thrombin synthesis. The latency of the speed of onset of the anticoagulant effect of warfarin is dependent primarily on the

rate of disappearance of the vitamin-K-dependent clotting factors that were preformed before commencing warfarin therapy.

Vitamin K deficiency (not Vitamin A), impairs blood coagulation and therefore enhances the action of warfarin.

Salicylates (such as aspirin) prolong prothrombin time by antagonizing the action of Vitamin K and inhibit platelet aggregation; these effects therefore enhance any warfarin anticoagulant action.

QUESTION 6

A 27 year-old lady is distressed to learn that she has had a miscarriage, with a 7 week non-viable pregnancy. This is her third in 4 years. On reviewing her notes you note a raised anti-cardiolipin antibody titre in her laboratory results section. What other clinical problem would fit with the diagnosis of anti-phospholipid syndrome?

A Pneumothorax B Arthritis C Photosensitive rash

D Deep venous thrombosis E Polycystic ovaries

Anti-phospholipid syndrome (APS) is a condition characterized by recurrent venous or arterial thrombosis and/or fetal losses in conjunction with persistently elevated levels of antibodies directed against membrane phospholipids typically anti-cardiolipin antibody. Several autoimmune diseases are associated with APS, the commonest being systemic lupus erythromatosis.

QUESTION 7

What is the diagnosis?

(a) Complete heart block

(b) Left bundle branch block

(c) Old infero-posterior infarct, and trifasciular

block(d) Acute posterior infarct

(e) 2nd degree heart block

The presence of Q waves in the inferior leads with small R waves, and the presence of a dominant R wave in V1 suggests an old infero-posterior myocardial infarction. The presence of right bundle branch block, left axis deviation and first degree atrio-ventricular block indicates tri-fascicular block.

QUESTION 8 A 65 year old man presents to you with fatigue and loss of

appetite. On examination: jaundice; palpable non-tender mass in the right upper quadrant.

The results of his liver function tests are below Albumin: 30 (35 - 50 g/L) ALK: 600 (39 - 117 U/L) ALT: 50 (5 - 40 U/L) Bilirubin: 80 (< 17 µmol/L) GGT: 220 (11 - 58 U/L) Urinalyis showed the presence of bilirubin. Urobilinogen was undetectable. Alpha feto-

protein was normal. What is the most likely diagnosis?

(a) Pancreatic carcinoma (b) Hepatocellular carcinoma (c) Hepatitis (d) Haemolytic anaemia (e) Alcoholic liver disease

In this case, there is a moderate rise in the liver enzyme ALT but a marked rise in the ALP which is suggestive of an obstructive/post-hepatic picture. The presence of bilirubin but absence of urobilinogen in the urine also supports this picture. Hepatocellular carcinoma may cause an obstructive picture, but the normal alpha feto protein suggests this is less likely. Therefore the most likely diagnosis here is pancreatic carcinoma. The diagnosis of the cause of jaundice cannot be made on the basis of the liver function tests alone. Other investigations such as ultrasonography, MRCP, ERCP, and CT should be considered.

QUESTION 9

A 60 year old woman attends with a lump in her right breast. The lump was noticed when she checked her breast after a fall on her chest. There is no nipple discharge. On examination there is a palpable fixed mass approximately 4cm x 3cm in the upper outer quadrant, with a smooth border. Mammogram showed a dense opacity. Histopathology ruled out breast cancer.

Which of the following is the most likely diagnosis?

A Duct papilloma

B Fat necrosis C Duct ectasia D Fibroadenoma E Breast cyst

The most likely diagnosis is fat necrosis. Fat necrosis typically occurs in elderly women with large breasts, or after injury to the chest, for example following a car accident when the seatbelt has squeezed the breast. This clinically presents as a firm painless lump, although there may be some redness or bruising. The only way to exclude breast cancer is FNAC. Fibroademomas, or "breast mice", typically affect young women between the ages of 15 and 25 years. They are usually well circumscribed, firm, smooth mobile lumps. Investigation with triple assessment (clinical breast exam, breast histopathology and radiology) can diagnose the condition and exclude breast cancer. Breast cysts and duct ectasia are disorders of involution that occur most often in older women. Breast cysts present as smooth discrete masses that can be painful. They are seen on mammography as "halos" and on ultrasound. Most cysts are asymptomatic and do not require treatment. Symptomatic cysts can be aspirated, but recurrence, or blood stained fluid on aspiration is an indication for surgical excision. Duct ectasia typically presents with cheesy discharge and "slit like" nipple retraction. Treatment is only indicated if the discharge is worrisome or if the patient wants their nipple everted. Duct papillomas are benign neoplasms that are very common. They usually present with blood-stained nipple discharge. Duct papillomas show little malignant potential, but treatment involves removal of the discharging duct, and allows exclusion breast cancer.

QUESTION 10 A 35 year old woman complains to you of a facial rash, with

purple discolouration of the eyelids and a swollen eye. She has also noticed some non-pruritic bluish/red nodules over her knuckles

What is the most likely diagnosis?

(a) Urticaria

(b) Dermatomyositis(c) Lichen planus

(d) Pityriasis rosea

(e) Granuloma annulare

This is the classic presentation of dermatomyositis. Dermatomyositis and polymyositis are rare disorders that involve inflammation of striated muscle causing weakness of proximal muscles. When the skin is involved, it is called dermatomyositis. Clinical features include facial erythema, a purple "heliotrope" rash on the eyelids and periorbital area. Bluish/red nodules typically occur on the extensor surfaces and over the knuckles (Gottron's papules). Diagnosis of the condition involves: Clinical appearance EMG reveals spontaneous fibrillation potentials at rest, short duration potentials on voluntary contraction and repetitive potentials on mechanical stimulation of the nerve Muscle biopsy which shows fibre necrosis and infiltration of inflammatory cells There is often a raised serum creatine phosphokinase.

QUESTION 11 A 25 year old woman notices a red, painful

rash on her shins.

Which of the following would you consider as a cause?

(a) Inflammatory bowel disease

(b) Oral contraceptive pill

(c) Post-streptococcal infection

(d) Sarcoidosis

(e) All of the above

The history is suggestive of erythema nodosum, which presents as painful nodules, usually on the extensor aspect of the lower limbs. It is most common in young adults, especially females. It is due to inflammation of the dermis and the subcutaneous layer (panniculitis). There may be associated arthralgia, malaise and fever.

Common causes of erythema nodosum include: Bacterial infections: streptococcal infections are the most

common cause of erythema nodosum. Drugs: The oral contraceptive pill, sulphonylureas and

sulphonamides have been implicated Sarcoidosis: Sarcodiosis is a multi-system disease. The most

common skin manifestation of the disease is erythema nodosum.

Inflammatory bowel disease, in particular, ulcerative colitis, have been associated with erythema nodosum.

Other less common causes include: Tuberculosis Hodgkin's lymphoma Pregnancy Idiopathic All patients presenting with erythema nodosum require a CXR

given the differential diagnoses.

QUESTION 13 A five year old Asian boy presents with a two

week history of being "off-form" with fever and lethargy. His parents also state that the skin on his hands have started to peel.

What important condition would you think of?

A Viral Meningitis B IgA Nephropathy C Henoch Schönlein Purpura D Idiopathic thrombocytopenic purpura (ITP)

E Kawasaki's disease

Fever and lethargy are presenting complaints for many childhood illnesses, but a child with persistent fever warrants special consideration.

Kawasaki's Disease is a vasculitis that affects medium sized blood vessels. Importantly it may involve the coronary vessels giving rise to aneurysms. The aetiology is unknown, but an infective trigger is suspected. Epidemiology of the disease reveals interesting secular trends with peaks in

the winter and early spring and a largely Japanese ethnic distribution. The disease is diagnosed if the following criteria are met (see box below:)

•Criteria for Diagnosis of Kawasaki's Disease: Fever > 5 days AND Four out of five from:

•Conjunctival injection •Mucous membrane changes •Cervical lymphadenopathy

•Rash •Extremities - erythema and peeling

QUESTION 14

Which of the following signs are not associated with severe pulmonary hypertension?

A Hepatomegaly B Right ventricular heave C Large V waves in the JVP

D Pan-systolic murmur loudest at the lower left sternal edge in expiration

E Peripheral oedema

The ductus arteriosus (DA) acts as a pulmonary circulation bypass during intrauterine life, returning oxygenated blood from the placental venous return to the systemic circulation. The DA should normally close within the first few hours or days after delivery, however, it can remain patent when it is termed a patent ductus arteriosus (PDA). The pulmonary pressure is lower than systemic pressure throughout the cardiac cycle. This pressure difference gives rise to the continuous murmur that is heard beneath the left clavicle, as blood crosses the patent ductus arteriosis. The murmur may be confused with the innocent murmur of a venous hum that can also be of the same grade and location. The venous hum can be distinguished from the murmur of a PDA by its disappearance on lying flat or on occlusion of the neck veins. These manoeuvres inhibit flow from the neck veins therefore abolishing the turbulent venous flow that causes the murmur.

QUESTION 15 A 42 year old man presented to his GP with troublesome

headaches mainly occurring at night. He describes them as excruciating, and during an attack his wife states that he becomes aggressive, noisy and has been known to kick furniture and walls. The headaches usually last about 60 minutes and occasionally his left eye becomes red and injected. It sometimes droops, making his wife think that he is having a stroke. He can sometimes have up to 6 attacks per night. Bad bouts occur every 3-4 months. He is well in between these episodes.

What is the diagnosis ? A Chronic migraine B Paroxysmal hemicrania C Short lasting unilateral neuralgiform headache with

conjunctival injection and tearing

D Cluster headache E Herald bleeds

This is a classical history for cluster headache. They tend to occur in middle aged men. They cluster. They typically last up to 180 minutes. They tend to occur at night and individuals tend to be restless during attacks. This is in contrast to migraine, when individuals classically take to their bed. There can be other autonomic symptoms of an injected eye and ptosis.

THANK YOU.