You are on page 1of 12

@ Medicine

A 32-year-old male is referred with chronic renal dysfunction . His


imaging is shown in Fig .
His blood pressure is consistently 140-150/90 mmHg.
Which of the following antihypertensives is the most appropriate for
the management of this man's blood pressure?

http://images.radiopaedia.org/images/557971/81974b96b5cdded5c46abb
2ad47df7.jpg
A. ACE inhibitor
B. Betablocker
C. Calcium channel blocker
D. Diuretic
A
Autosomal dominant APKD-1 is a relatively common disorder
accounting for approximately 8% of cases of end-stage renal disease
(ESRD).

"The best drugs for this condition are ACE inhibitors (ie, captopril,
enalapril, lisinopril) or angiotensin II receptor antagonist blockers (ie,
telmisartan, losartan, irbesartan, candesartan). Calcium channel
blockers are not encouraged to be used."
However, although widely used and recommended, there is no
evidence that the renin-angiotensin system is affected in the disease.
@ Medicine A 42-year-old female with dysentery has undergone
endoscopy shown in Fig is found to have anti-smooth muscle
antibodies.
Which is the most appropriate next test for this patient?

http://image.slidesharecdn.com/ulcerativecolitis-150221154520conversion-gate02/95/ulcerative-colitis-17-638.jpg?cb=1424555200
A. Abdominal ultrasound
B. Colonoscopy
C. Liver function tests
D. Liver biopsy
Ans C
Ulcerative colitis on endoscopy : The most appropriate investigation for
this woman is LFTs to begin with to assess if there are any features of

autoimmune hepatitis, such as, raised bilirubin, aspartate


aminotransferase (AST), alanine aminotransferase (ALT) and alkaline
phosphatase.
If this is the case then liver biopsy may be required or further
diagnostic imaging.
Autoimmune hepatitis is often seen in individuals with other
autoimmune disorders such as ulcerative colitis.
@ Ophthalmology Which one of the following diseases is most likely to
be associated with conditions shown in Fig ?

http://emedsa.org.au/EDHandbook/eyes/redeye/Scleritis.jpg
A. Ankylosing spondylitis
B. Crohn's disease
C. Rheumatoid arthritis
D. SLE
C
Scleritis refers to inflammation that occurs throughout the entire
thickness of the sclera, and it is usually more severe than episcleritis. It
typically has a subacute onset, with pain being a dominant feature.

Around 50% of patients with scleritis have an underlying disease, of


which the majority are connective tissue disorders. Rheumatoid
arthritis is the most common. It can also be seen in:
systemic lupus erythematosus (SLE)
reactive arthritis
polyarteritis nodosa
ankylosing spondylitis
gout
Churg-Strauss syndrome
syphilis, and
Wegener's granulomatosis (but much less commonly).
@Medicine
A 45-year-old male with type 1 diabetes and with a number of complex
diabetic gastrointestinal complications has undergone ECG shown in
Fig .
Which of the following drugs most likely to be responsible?

http://askdrwiki.com/mediawiki/images/thumb/f/ff/LongQT045.jpg/750p
x-LongQT045.jpg
A. Cimetidine
B. Co-trimoxazole
C. Domperidone
D. Erythromycin
D
Erythromycin has been associated with prolonged QT interval and
torsades de pointes, and is used in diabetic gastropathy, although its
benefits in the condition are not entirely understood. Rarely,
domperidone has been reported to prolong QT.
Prolonged QT is defined as greater than 0.45 s.
Other agents include amitriptyline and phenothiazines yet
metoclopramide and domperidone are not associated.

@ Pathology
A 32-year-old man was prescribed an oral antibiotic for a urinary tract
infection.
Two days later he noticed that his urine was increasingly dark in colour.
Investigations revealed:
Haemoglobin
85 g/L
(130-180)
Reticulocytes
147 109/L (25-85)
Peripheral smear is shown in Fig .
What is the most likely diagnosis?

http://classconnection.s3.amazonaws.com/202/flashcards/15202/png/bi
te_cells1361211836621.png
A. Acute myeloid leukaemia
B. Autoimmune haemolytic anaemia
C. Paroxysmal cold haemoglobinuria
D. Hereditary spherocytosis
B
Blood film: marked anisopoikilocytosis and bite cells.
Paroxysmal cold haemoglobinuria (PCH) is a rare type of autoimmune
haemolytic anaemia (AIHA) occurring primarily in children.
The classic symptom of PCH is a sudden onset of haemoglobinuria
following exposure to cold, even for a few minutes. Symptoms may
occur minutes to hours following exposure to cold. Haemoglobinuria is

not always present because in some persons with PCH the


autoantibody level is not high enough to cause intravascular
haemolysis. PCH is usually of abrupt onset in the setting of an
infectious disease.
Given the patient's age and the specific history in this case the
diagnosis is unlikely to be PCH.
If the diagnosis were hereditary spherocytosis then the blood film
would show spherocytes.
In haemoglobin H disease the typical inclusions can be demonstrated in
erythrocytes stained with brilliant cresyl blue and a chronic microcytic,
hypochromic anaemia would be present.
Haemolytic anaemia may be precipitated by sulfonamides and also by
penicillins.
This gentleman may have been treated with trimethoprim or a
penicillin which then caused AIHA with the typical blood film.
The most appropriate answer to this question is autoimmune
haemolytic anaemia, given the patient's age, the lack of history of
exposure to cold, and the history which is given of antibiotic
prescription.
@ Microbiology
A 19-year-old male student attends the Emergency department
complaining of an urethral discharge one week after having casual
unprotected sex.
Gram stain is shown in Fig The patient is treated with ceftriaxone, 250
mg as an intramuscular injection. Five days later, the patient re-attends
with persisting discharge.
Which of the following is the most likely cause of this discharge?

http://clinicalgate.com/wp-content/uploads/2015/04/image108214.jpeg
A. Chlamydia trachomatis
B. Penicillin-resistant Neisseria gonorrhoeae
C. Re-infection with Neisseria gonorrhoeae

D. Ureaplasma urealyticum
A
Fig : Gram's stain of urethral discharge from a male patient with gonorrhea shows gramnegative intracellular monococci and diplococci.

Gonorrhoea is one of the commonest reported STDs in both men and


women. In men the symptoms manifest as urethritis and in women
cervicitis or urethritis.
This patient has been adequately treated for gonorrhoea and a
persistent discharge would be unusual unless there is antibiotic
resistance in which case a culture assay will help to determine
sensitivities.
More commonly patients present with co-infection with Chlamydia
trachomatis.
In this case the patient is likely to have a non-specific urethritis (NSU)
due to Chlamydia trachomatis, requiring treatment with either
doxycycline or erythromycin for 7-14 days.

@Medicine
A 49-year-old city worker attends for evaluation of erectile dysfunction.
He has mild hypertension for which he takes amlodipine 5 mg daily, but
no other past medical history of note. He admits to working long hours
and spends a great deal of time entertaining clients.
On examination his BP is 145/82 mmHg, his pulse is 70 and regular and
his BMI is 31.
Investigations show:
Haemoglobin
105 g/L
(135-177)
White cell count 6.8 109/L (4-11)
Platelets 197 109/L (150-400)
Sodium 139 mmol/L (135-146)
Potassium
4.0 mmol/L (3.5-5)
Creatinine
117 mol/L (79-118)
Alkaline phosphatase 130 U/L
(39-117)
Alanine aminotransferase
160 U/L
(5-40)
His physical examination is shown in Fig .
Which of the following is the most likely diagnosis?

http://img.tfd.com/medical/Davis/Tabers/th/g27.jpg
A. Chronic alcoholism
B. Cushing's syndrome
C. Haemochromatosis
D. Klinefelter's syndrome
A
He has obvious bilateral gynaecomastia.
This patient's lifestyle is likely to be associated with heavy alcohol
consumption. This has resulted in abnormal liver function tests and
weight gain. The gynaecomastia may be related purely to obesity or to
increased peripheral production of oestrogens coupled with decreased
hepatic metabolism of sex steroids. Erectile dysfunction is also of
course related to alcohol consumption.
Given the history we are provided with, and the fact this patient only
has mild obesity and controlled hypertension, Cushing's is unlikely.
Haemochromatosis could be considered if when challenged, this
patient denied excess alcohol consumption.
Klinefelter's would not fit well with this phenotype and earlier
presentation would be expected.
Simple obesity should not be associated with other medical conditions.

@ Medicine
A 34-year-old male presents with palpitations. The ECG is shown in Fig
What is the treatment of choice?

http://cdn.lifeinthefastlane.com/wpcontent/uploads/2010/04/ECG90113-WPW.jpg
A. Amiodarone
B. Aspirin
C. Diltiazem
D. Radiofrequency ablation
D
The ECG shows a slurred upstroke in the QRS complexes in the chest
leads.
This patient has Wolff-Parkinson-White syndrome as suggested by the
delta wave on ECG.
Anticoagulation is not indicated.
Risk of arrhythmia after ablation is of the order of 7% over five years.
@ Medicine
A 35 year-old woman presented with a five year history of weight gain
associated with a one year history of amenorrhoea.

Over this time she had been trying to conceive.


On examination, she had a BMI of 32 kg/m2, a pulse was 84 beats per
minute, and a blood pressure of 154/100 mmHg.
Physical examination is shown in Fig .
Which of the following would be the most useful initial investigation?

http://www.physio-pedia.com/images/6/61/Moon_facies_in_Cushings.jpg
A. 24 hour urinary free cortisol (UFC) concentration
B. Combined 9 am ACTH concentration and serum cortisol
concentration
C. Midnight cortisol concentration
D. The 1 mg overnight dexamethasone suppression test (ODST)
A
Of 1 mg ODST or UFC, either test would be appropriate, but UFC is
often recommended and has a 95% specificity (85% specificity in the
obese) and a 98% sensitivity.
It is however important to recognise that these values for specificity
and sensitivity only apply to a high threshold for abnormal urinary free
cortisol, set at 3-4 times the upper limit of the normal range. A number
of patients with Cushings may therefore not fulfil the criteria for
diagnosis of Cushings based on UFC alone.
The ODST has a sensitivity and specificity of 98% and 75-80% in obese
subjects with a cut-off value of 50 nmol/L.
Therefore, purely for convenience sake, a UFC would probably be the
expected response here.
Midnight cortisol is pointless as a screening test expecting the patient
to be fast asleep when blood is taken.

Sodium and potassium concentrations offer nothing, nor do ACTH and


cortisol.
@ Medicine
A 35-year-old lady presented with left-sided weakness.
She has a young family with a 5-year-old son and a 2-year-old
daughter. Previously she had two spontaneous abortions. After the birth
of her last child she developed a deep vein thrombosis (DVT) and
received three months of anticoagulation with warfarin.
On examination she has left-sided weakness with pyramidal signs. A CT
head scan is shown in Fig
Which of the following is the most likely diagnosis?

http://www.mypacs.net/repos/mpv3_repo/viz/full/120/6021.jpg
A. Antiphospholipid antibody syndrome
B. Hypertension
C. Kawasaki syndrome
D. Thrombotic thrombocytopenic purpura
A
This patient has a prothrombotic tendency suggestive of
antiphospholipid syndrome with recurrent abortions, previous DVT and
now she has developed a left hemiparesis suggesting venous sinus
thrombosis.

This patient has antiphospholipid antibody syndrome (APAS). APAS can


be diagnosed if the patient has anticardiolipin antibodies, or lupus
anticoagulant on two occasions, over a period of 12 weeks, and has
had either:
a thrombus, or
a history of recurrent <10 week pregnancy loss, or one pregnancy loss
>10 weeks in gestation when other causes of pregnancy loss have
been excluded.
The occurrence of even a single thrombotic event in a patient with
antiphospholipid syndrome warrants lifelong anticoagulation, as the
risk of recurrence is 20-70%. Low molecular weight heparin should be
used initially whilst loading warfarin. In general, it is recommended that
the INR is maintained above 2.0, although a higher level (above 3) may
be indicated for patients with recurrent thrombosis on treatment.
Anticoagulation to prevent fetal loss remains controversial.
Of the options given here, only SLE is commonly associated with
antiphospholipid syndrome and is therefore the correct answer.

You might also like