Clinical SBAs
Clinical General Medicine: (30 questions)

Questions

• 1
  26-year old woman attends A&E stating she has taken 36 paracetamol tablets 5 hours ago after a fight with her partner. She is distressed but asymptomatic and examination is normal. Which of the following is least likely to be included in this patient’s management?
  Difficulty: Medium     Topic: Paracetamol overdose 1
  a

  Plasma paracetamol concentration

  b

  Clotting studies

  c

  U&E

  d

  Activated charcoal

  e

  IV N-acetyl-cysteine (NAC)
  Explanation: >150mg/Kg of paracetamol is a potentially lethal dose, as in this case. Activated charcoal is only useful if used <1hr of ingestion, any longer than this and there will have been significant absorption already. Plasma concentration should be measured >4hrs but not before; this guides the need for treatment with NAC, if begun <8hrs the prognosis is very good. INR is the best maker for severity of hepatic damage and correlates with survival. U&E are important because in overdose paracetamol also causes acute tubular necrosis. Haemofiltration with admission to ITU is often needed to support renal function.
• 2
  A 40-year old man is recovering from an emergency laparotomy for a perforated duodenal ulcer. 10 days later he develops an intermittent pyrexia, upper abdominal pain with localised guarding and hiccups. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Intermittent pyrexia and hiccups
  a

  Spontaneous bacterial peritonitis

  b

  Anastamosis dehiscence

  c

  Subphrenic abscess

  d

  Mesenteric ischaemia

  e

  Empyema
  Explanation: An intermittent pyrexia (or 'swinging fever') is suggestive of an abscess. Hiccups result from: ileus, uraemia and irritation of the diaphragm e.g. subphrenic abscesses. Thorough wash-out is required after perforation to ensure that abscesses do not develop. Spontaneous bacterial peritonitis and anastamotic dehiscence present with generalised peritonitis and a constant fever. Mesenteric ischaemia would present with abdominal pain and an absence of signs, rarely fever. An empyema would cause chest pain and usually occurs post-pneumonia.
• 3
  A 28-year old man presents having stepped on a rusty nail, which has entered his foot. He completed his course of tetanus toxoid immunisation 10 years ago. What is the most appropriate course of action for tetanus prophylaxis?
  Difficulty: Medium     Topic: Tetanus prophylaxis
  a

  No further treatment needed

  b

  Booster dose of toxoid

  c

  Commence immunisation course

  d

  Booster dose of toxoid plus passive immunisation

  e

  Immunisation course plus passive immunisation
  Explanation: Wounds potentially contaminated with Clostridium tetani are those that are penetrating and dirty, therefore may become anaerobic. If a full course has previously been completed then a booster of toxoid should be given. If the course has not been completed then anti-tetanus immunoglobulin is given as passive immunisation and the full course of active immunisation is begun.
• 4
  What abdominal operation typically results in formation of an ileostomy?
  Difficulty: Medium     Topic: Ileostomy
  a

  Gastric outlet bypass

  b

  Hartmann's procedure

  c

  Oesophagectomy

  d

  Panproctocolectomy without anal reconstruction

  e

  Whipple's resection
  Explanation: UC and Crohn's may result in permanent ileostomy following pancolectomy or as a diversion when primary anastamosis has been performed. Gastric outlet obstruction may be treated surgically with a gastro-ileal bypass. Hartmann's procedure is an emergency operation for sigmoid pathology, resulting in a colostomy. Oesophagectomy may involve a defunctioning pharyngostomy but primary anastamosis, plus use of a chest drain is common practice. Whipple's resection is used for carcinoma of the pancreatic head. The operation involves a partial gastrectomy and duodenectomy with anastamosis onto the jejunum, which also connects to the common bile duct via a Roux loop but there is no ileostomy.
• 5
  A 60-year old man with varicose veins presents with a groin lump that lies inferior and lateral to the pubic tubercle. What clinical feature is most consistent with the diagnosis?
  Difficulty: Easy     Topic: Lump with varicose veins
  a

  It disappears on lying flat

  b

  Cough impulse is absent

  c

  It is resonant to percussion

  d

  It is non-fluctuant

  e

  It is very painful
  Explanation: This man has a saphena varix, a dilatation of the junction between the femoral vein and the great saphenous vein. It may be a cause of incompetence in varicose veins or associated with other levels of incompetent valves. A saphena varix appears to disappear on pressure or when lying down therefore appears to reduce. The other features may be present with a femoral hernia, which are more common in women but lie in a similar anatomical position to a saphena varix. Femoral hernias are resonant due to the presence of bowel but if they obstruct then a cough impulse may not be present. A strangulated femoral hernia may lose fluctuance as it becomes inflamed and will be extremely painful.
• 6
  A 62-year old woman presents with a firm lump immediately lateral to the mid-point between the ASIS and the pubic symphysis. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Firm inguinal lump
  a

  Inguinal hernia

  b

  Psoas abscess

  c

  Femoral artery aneurysm

  d

  Femoral neuroma

  e

  Inguinal lymphadenopathy
  Explanation: The mid-inguinal point is the position of the femoral pulse. (The mid-point of the inguinal ligament is the position of the deep ring.) Immediately lateral the artery is the femoral nerve and a firm lump suggests a neuroma. An inguinal hernia will be superomedial to the pubic tubercle. A psoas abscess would be more lateral and fluctuant; it causes pain on passive hip flexion. Femoral artery aneurysm is expansile and pulsatile. Inguinal lymph nodes are medial to the femoral vein.
• 7
  A 46-year old man presents with fever, pain on hip flexion and a fluctuant swelling immediately medial to the anterior superior iliac spine. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Fluctuant inguinal swelling
  a

  Femoral hernia

  b

  Femoral aneurysm

  c

  Saphena varix

  d

  Psoas abscess

  e

  Ectopic testis
  Explanation: Psoas major passes lateral to the femoral nerve before it inserts on the lesser trochanter. Abscesses are most commonly due to TB and may be related to lumbar infection (Pott's disease of the spine). Other features include: systemic upset, weight loss, swinging fever and pain on passive hip flexion. None of the other pathologies lie immediately medial to the ASIS, they lie further towards the midline. A femoral hernia and saphena varix lie inferolateral to the pubic tubercle. An aneurysm is expansile, pulsatile and medial to the femoral nerve. Ectopic testis is most likely to be in the abdomen or the inguinal canal therefore superomedial to the femoral nerve.
• 8
  A 25-year old man presents with 30minutes of acute abdominal pain, what is the least likely diagnosis?
  Difficulty: Easy     Topic: Medical acute abdomen
  a

  Familial Mediterranean fever

  b

  Pan-hypopituitarism

  c

  Henoch-Schonlein syndrome

  d

  Pneumonia

  e

  Angina
  Explanation: Angina very rarely causes abdominal pain and it would resolve on rest therefore does not last for 30min. Abdominal pain of cardiac-origin that has lasted 30minutes is most likely to be an inferior MI in a diabetic patient. FMF causes intermittent peritonitis, fever and malaise due to a genetic defect. Pan-hypopituitarism can cause an acute Addison's crisis with abdominal pain and shock. Henoch-Schonlein syndrome is a vasculitis most affecting teenage boys that often involves the bowel, causing abdominal pain and GI bleeds as well as haematuria and palpable purpura on the lower limbs. Basal pneumonia may present as upper quadrant pain with an absence of signs.
• 9
  A previously well 69-year old man presents with fatigue and anaemia; is found to have irregular hepatomegaly. Which of the following blood tests is most likely to be raised?
  Difficulty: Medium     Topic: Causes of hepatomegaly
  a

  Alpha-feto protein (AFP)

  b

  Beta-human chorionic gonadotrophic (B-HCG)

  c

  Carcinoembryonic antigen (CEA)

  d

  CA125

  e

  CA15-3
  Explanation: The most common causes of hepatomegaly are: early alcoholic liver disease or fatty liver disease, right-sided heart failure and colorectal metastases. She most likely has colorectal cancer, which can be asymptomatic unlike late. CEA is raised in most CRC and is used for monitoring (not diagnosis). AFP is raised in hepatocellular carcinoma, which is rare in the absence of cirrhosis or hepatitis B. B-HCG is raised in testicular teratomas and pregnancy. CA125 is raised in ovarian carcinoma, an unlikely cause of hepatic metastases in a man. Unlike most other cancer markers, CA125 may have a role in diagnosis of pelvic masses. CA15-3 is a cancer maker most specifically raised in breast cancer, which can be used to detect relapse following treatment.
• 10
  A 37-year old woman presents with a 4 month history of diarrhoea, weight loss and abdominal pain. A tender, poorly defined right iliac fossa mass is found on examination. What is the most likely diagnosis?
  Difficulty: Medium     Topic: RIF masses
  a

  Crohn's mass

  b

  Tuberculous mass

  c

  Appendix mass

  d

  Caecal carcinoma

  e

  Carcinoid tumour
  Explanation: Diarrhoea, pain and weight loss in a 30-40yr old woman is highly suggestive of Crohn's. Inflammation of the terminal ileum results in a poorly defined, tender RIF mass that is known as a "Crohn's mass". TB causes 'cold', non-tender abscesses from previous infection that may form a sinus. Appendix mass forms post-appendicitis and unless an abscess develops it is mostly asymptomatic. Caecal carcinoma is insidious in presentation and causes anaemia but less commonly a change of bowel habit. Carcinoid tumour has similar features but is not tender.
• 11
  A thin 22-year old man presents with fatigue and pyrexia. A smooth, firm 5cm mass is palpable in his umbilical region. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Smooth umbilical mass
  a

  Bowel cancer

  b

  Hodgkin's lymphoma

  c

  Non-Hodgkin's lymphoma

  d

  Dermoid cyst

  e

  Aortic aneurysm
  Explanation: This man has para-aortic lymphadenopathy. It would transmit a pulse because it is overlying the aorta however it will not be expansile, which would suggest an aneurysm. A dermoid cyst will be fluctuant, lies more superficially and does not cause fatigue. Bowel cancer could present with an abdominal mass however it would be very rare for bowel cancer to present with these symptoms, in a young man and in that anatomical location. Hodgkin's lymphoma peaks at 20-30yrs, whereas NHL increases with age.
• 12
  A 71-year old woman presents with a history of fatigue, anorexia and weight loss. She is found to have generalised abdominal swelling. Her whole abdomen feels firm and irregular. Shifting dullness is present. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Firm, irregular abdomen
  a

  Ovarian carcinoma

  b

  Endometrial carcinoma

  c

  Hepatic cirrhosis

  d

  Gastric carcinoma

  e

  Ductal carcinoma of the breast
  Explanation: A firm and irregular abdomen with ascites suggests omental carcinomatosis, which are multiple small malignant deposits throughout the abdomen. In post-menopausal women this is most commonly from ovarian carcinoma and can be caused by endometrial and gastric less frequently. Cirrhosis would not give an irregular abdomen, though the ascites may be tense. Ductal carcinoma of the breast may metastasise to the peritoneum but it is rare.
• 13
  A 55-year old man is recovering from necrotizing pancreatitis caused by gallstones that he suffered from 2 weeks ago. He is found to have an epigastric mass that is difficult to localise and does not move with respiration. Amylase is 327IU/L. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Epigastric masses
  a

  Hepatocellular carcinoma

  b

  Gastric carcinoma

  c

  Alcoholic liver disease (ALD)

  d

  Pseudocyst

  e

  Splenomegaly
  Explanation: A pseudocyst is a collection of fluid in the lesser sac, a complication of necrotizing pancreatitis. It is a retroperitoneal mass therefore is difficult to localise and is a cause of a persistently raised amylase. Hepatocellular carcinoma is the most common malignant primary liver tumour however it almost always occurs with a history of cirrhosis or hepatitis B infection. His pancreatitis was caused by gallstones, which is not a risk factor for cirrhosis or HCC. Gastric carcinoma presenting as a mass will be more easily localised. It causes symptoms of gastric outlet obstruction and does not result in a grossly raised amylase unless there is complete bowel obstruction. Splenomegaly moves with respiration and amylase is not raised. ALD presents as acute liver failure (due to alcoholic hepatitis), decompensation of cirrhosis or asymptomatically with signs of chronic disease.
• 14
  A 68-year old woman presents with 2 months of intermittent cramping lower left quadrant pain and diarrhoea, which partly relieves the pain. What is the most appropriate management?
  Difficulty: Medium     Topic: Cramping pain and diarrhoea
  a

  Reassurance and advice on IBS diet

  b

  Routine blood tests and reassurance

  c

  Routine blood tests and buscopan

  d

  Routine blood tests and sigmoidoscopy

  e

  Routine blood tests and colonoscopy
  Explanation: This woman has presented with symptoms consistent with IBS according to the Rome II criteria, however it is still appropriate to investigate for malignancy. Initial presentation of IBS at over 50 years is rare and the symptoms may be due to colorectal cancer. Though the majority of colon-rectal cancer can be seen on sigmoidoscopy, colonoscopy is required to exclude caecal carcinoma. 'A-C' may all be used to treat irritable bowel syndrome depending on appropriate history and examination findings.
• 15
  What is the best investigation to confirm a congenital remnant of the vitelline duct?
  Difficulty: Hard     Topic: Congenital malformation
  a

  CT scan

  b

  MRI

  c

  CT angiography

  d

  Radionucleotide scan

  e

  Colonoscopy
  Explanation: Meckel's diverticulum is the remnant of the vitelline duct that is present in the terminal ileum of 2% of the general population. It shows gastric heterotopia (gastric mucosa is present) and a Tc-99 labelled scan can be used to detect it. As it lies proximal to the ileo-caecal valve, colonoscopy will not visualise it. MRI and CT may show the diverticulum but are less likely to than nuclear imaging. CT angiography can be used for angiodysplasia or mesenteric ischaemia.
• 16
  An 82-year old lady has fractured hip after a fall. She has hypertension (treated with bendroflumethiazide and ramipril) and thyrotoxicosis. She was a smoker until her stroke 5 years ago. Urine is positive for blood, nitrites and leukocytes. Which of the following statements is incorrect?
  Difficulty: Medium     Topic: Multifactorial falls
  a

  Examination would show a shortened, internally rotated lower limb

  b

  Urine infection with E. coli contributed to the fall

  c

  She has at least 3 risk factors for osteoporosis

  d

  Examination may reveal postural hypotension

  e

  She has 3 risk factors for stroke
  Explanation: Fractured neck of femur (NOF) is common, especially with osteoporosis. If displaced, fractured NOF causes a shortened and externally rotated leg. Whereas hip dislocation causes an internally rotated leg, this difference is due to the action of iliopsoas. Urine dipstick suggests infection, which is likely to contribute. Osteoporosis risk factors: hyperthyroidism, smoking, old age, steroids, alcoholism. Postural hypotension may be present due to over treatment of hypertension. >75yrs, smoking and hypertension are stroke risk factors.
• 17
  A 28-year old man of Pakistani origin is referred with 3 months pyrexia, weight loss and anorexia. He reports abdominal pain after drinking alcohol. FBC, U&E and sputum culture are normal but LDH is raised. CXR is normal. Abdominal ultrasound shows para-aortic lymphadenopathy. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Pyrexia with raised LDH
  a

  Renal cell carcinoma (RCC)

  b

  Tuberculosis

  c

  Sarcoidosis

  d

  Peri-aortitis

  e

  Lymphoma
  Explanation: Hodgkin's disease peaks in young adults and is the most likely cause. It more commonly arises in the anterior cervical chain but may arise anywhere, including para-aortic lymph nodes. He also is experiencing B-symptoms and has raised LDH, therefore has poorer prognosis. Lymph node pain with alcohol can occur with HD. Staging of Hodgkin's disease uses the Ann Arbor system, which uses the location of lymph nodes on either side of the diaphragm, organ involvement and the presence of B-symptoms. RCC has haematogenous spread to the lungs rather than lymphatics. Tuberculosis is unlikely due to normal culture and CXR, which also excludes sarcoidosis. Peri-aortitis (retroperitoneal fibrosis) does not cause lymphadenopathy.
• 18
  A 27-year old man returns from Sub-Saharan Africa unwell, pyrexial and with splenomegaly. He is anaemic, jaundiced and there are ring form inclusions in his red cells. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Pyrexia and splenomegaly
  a

  Schistosomiasis

  b

  Hepatitis A virus

  c

  Hepatitis B virus

  d

  Malaria

  e

  Infective endocarditis
  Explanation: Malaria is caused by Plasmodium species, which are ring-shaped protozoan that infect RBC and cause haemolysis. P. Falciparum has the highest mortality. Other features include: periodic fever that peaks every 3-4days, reduced consciousness from cerebral involvement, metabolic acidosis, hypoglycaemia and pulmonary oedema. It is treated with artemisinins. None of the other conditions infect RBC though all can cause jaundice.
• 19
  A 43-year old diabetic woman presents with dull chest pain that comes on after eating. It is worse at night or when lying down. she drinks 10-15 units of alcohol a week. She is prescribed sublingual GTN but it does not help. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Chest pain after eating
  a

  Angina pectoris

  b

  Decubitus angina

  c

  Prinzmetal’s angina

  d

  Gastro-oesophageal reflux disease

  e

  Oesophageal spasm
  Explanation: Chest pain that is worse when lying down and without relief from GTN is most likely to be GORD. It also causes: cough, dyspepsia and relief with antacids. All the other options are relieved by GTN. Atherosclerotic angina can be brought on by eating. Decubitus angina is when pain is precipitated by lying down and usually suggests severe disease. Prinzmetal's angina is coronary artery spasm that can co-exist with atherosclerosis. GTN reduces pain from oesophageal spasm over 10-15minutes, unlike 2-3minutes in angina.
• 20
  A 58-year old man is confused on the ward. His JVP is not raised and he is found to have a sodium of 118 mmol/L. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Euvolaemic hyponatraemia
  a

  Sampling error

  b

  DKA

  c

  SSRI side-effect

  d

  Excess 5% dextrose administration

  e

  Addison's disease
  Explanation: The causes of hyponatraemia can be divided by volume status. Excess 5% dextrose administration is a common cause of hyponatraemia, especially in elderly patients with poor renal function and inadequate dietary intake. Taking blood from an arm receiving 5% dextrose IV would result in a spurious hyponatraemia. Whilst this must be excluded, the patient's clinical condition is consistent with hyponatraemia. In DKA there is loss of fluid from polyuria but with more water reabsorption than sodium, causing hypovolaemic hyponatraemia. SIADH (syndrome of inappropriate ADH secretion) as a side-effect of SSRI is the only euvolaemic cause. Addison's disease causes inability to reabsorb sodium therefore hypovolaemia.
• 21
  A 60-year old lady presents with fatigue. On observation she is thin and appears tanned. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Fatigue and tanned
  a

  Haemochromatosis

  b

  Peutz-Jeghers syndrome

  c

  Addison's disease

  d

  Conn's syndrome

  e

  Pan-hypopituitarism
  Explanation: Hyperpigmentation in Addison's occurs due to increased ACTH release. As ACTH is cleaved from its precursor (POMC) melanocyte-stimulating hormone is produced, which increases the rate of production of melanin. This is not present in panhypopituitarism because there is reduced ACTH production. Haemochromatosis causes a 'slate-grey' appearance rather than tanned. Peutz-Jegher's causes perioral freckling.
• 22
  A 60-year old woman presents with intermittent flushing. She also complains of shortness of breath, diarrhoea and weight loss. Examination shows a pan-systolic murmur at the left sternal border that does not radiate. What is the most likely underlying diagnosis?
  Difficulty: Medium     Topic: Intermittent flushing and systolic murmur
  a

  Churg-Strauss syndrome

  b

  Carcinoid syndrome

  c

  Ischaemic cardiomyopathy

  d

  Crohn's disease

  e

  Polyarteritis nodosa
  Explanation: Carcinoid tumours are slow growing tumours that can arise anywhere but most commonly in the GI tract (usually in the appendix) or lungs. If of GI-origin the only become symptomatic when liver metastases prevent hepatic clearance of the secreted substances. Heart failure may occur because carcinoid syndrome causes valvular lesions (e.g. tricuspid regurgitation, as in this case). Diagnosis uses 24-hour urine collection for 5-HIAA, a breakdown product of 5-HT. Medical treatment is with octreotide, a somatostatin analogue, which is highly effective.
• 23
  A 67-year old diabetic man presents with a painful ankle. The overlying skin is red and oedematous, which extends onto the foot. He is pyrexial. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Swollen, red ankle
  a

  Cellulitis

  b

  Charcot's joint

  c

  Pseudogout

  d

  Gout

  e

  Septic arthritis
  Explanation: Diabetic patients are at higher risk of all the above conditions and all may cause a swollen, erythematous ankle. Presence of the rash spreading onto the foot suggests that the pathology is not confined to the ankle, which favours cellulitis. He is pyrexial, which makes gout, Charcot's joint and pseudogout unlikely. Cellulitis is most commonly caused by Staphylococcus aureus and first line treatment is flucloxacillin. The area of erythema should be marked to watch for spread.
• 24
  A 74-year old man collapses while watching an aeroplane demonstration. He has a history of hypertension and osteoarthritis. He describes pain in his neck then becoming light headed before passing out. Which of the following investigations would give the diagnosis?
  Difficulty: Medium     Topic: Collapse
  a

  CT head

  b

  MRI head

  c

  X-ray head, neck and spine

  d

  Standing and lying blood pressure

  e

  FBC, U&E and ESR
  Explanation: This man has experienced syncope due to vertebrobasilar insufficiency, which occurs from osteophytic compression of the vertebral arteries on neck extension that causes transient cerebral hypoperfusion. Imaging of the cervical spine will demonstrate the bony spurs, and X-ray is sufficient. CT or MRI neck would give the diagnosis, but not just the head. Standing and lying BP would help diagnose postural hypotension. Baseline bloods are useful however aren't diagnostic.
• 25
  A 78-year old woman with COPD presents with right upper quadrant pain. A pan-systolic murmur is heard at the left sternal edge and there is a pulsatile mass in the right upper quadrant. What is the most likely diagnosis?
  Difficulty: Easy     Topic: COPD and systolic murmur
  a

  Hepatic angiomyolipoma

  b

  Constrictive pericarditis

  c

  Right heart failure

  d

  Splenic artery aneurysm

  e

  Gall bladder carcinoma
  Explanation: Hepatomegaly from venous congestion in right heart failure causes pain from stretch of the liver capsule. Long-standing COPD causes cor pulmonale and dilatation of the right ventricle results in functional tricuspid regurgitation. Hepatic tumours can cause bruits but not murmurs. Constrictive pericarditis causes right-heart failure but not tricuspid regurgitation. Splenic artery aneurysm may cause a bruit in the left upper quadrant. Gall bladder cancer does not cause a murmur.
• 26
  Which of the following is a sign of chronic liver disease?
  Difficulty: Medium     Topic: Signs in the hands 3
  a

  Beau’s lines

  b

  Terry’s nails

  c

  Mees’ lines

  d

  Nail pitting

  e

  Onycholysis
  Explanation: Terry’s nails are see in chronic liver disease and renal failure. The proximal half is white and the distal part is red. Beau's lines are horizontal grooves in nails that are caused by: chemotherapy, MI and infection. Mees's lines are single white horizontal lines in renal failure. Pitting of nails is caused by psoriasis, reactive arthritis and vitiligo. Onycholysis is separation of the nail from the bed and is due to infection or psoriasis.
• 27
  Which of the following is not associated with palmar erythema?
  Difficulty: Easy     Topic: Signs in the hands 2
  a

  Cirrhosis

  b

  Rheumatoid arthritis

  c

  Pregnancy

  d

  Phaemochromocytoma

  e

  Polycythaemia rubra vera
  Explanation: Palmar erythema is a red discolouration of the palm, most found over the thenar and hypothenar eminences. There are many causes, including: cirrhosis, rheumatoid arthritis, pregnancy, polycythaemia, hyperthyroidism and some drugs. Phaemochromocytoma is a tumour of enterochromaffin cells, almost always in the adrenal medulla. The majority are benign and it is associated with VHL and MEN IIA and IIB syndromes. It causes intermittent hypertension, flushing, anxiety and abdominal pain.
• 28
  Which of the following is not consistent with a diagnosis of amyloidosis?
  Difficulty: Medium     Topic: Amyloidosis diagnosis
  a

  Red-green birefringence under polarised light

  b

  History of bronchiectasis

  c

  Increased cardiac echogenicity

  d

  Carpal tunnel syndrome (CTS)

  e

  Chronic renal failure with small kidneys
  Explanation: Amyloidosis is systemic deposition of protein resistant to degradation. There are two forms, AL (primary) due to clonal plasma cell proliferation with production of amyloid protein; and AA (secondary) due to chronic inflammation or infection. Amyloidosis causes chronic renal failure but with large kidneys. Diagnosis uses biopsy with Congo Red stain. Bronchiectasis (and all suppurative lung disease) can cause AA amyloidosis. AL causes restrictive cardiomyopathy, with increased echogenicity. CTS occurs from deposition under the flexor retinaculum.
• 29
  Which of the following is the most appropriate treatment for motion sickness?
  Difficulty: Medium     Topic: Anti-emetics
  a

  Dexamethasone

  b

  Cyclizine

  c

  Metoclopramide

  d

  Haloperidol

  e

  Ondansetron
  Explanation: Motion sickness is stimulated in the vestibular labyrinth, which predominantly uses histamine signalling. Cyclizine is an antihistamine, which is effective for chemical causes and motion sickness. Dexamethasone is a steroid best used in combination with ondansetron (a 5HT-antagonist) for prevention of post-operative nausea and chemotherapy-associated emesis. Metoclopramide is a dopamine antagonist and pro-kinetic agent that is used for ileus but contraindicated in mechanical bowel obstruction. Haloperidol is an atypical antipsychotic best for chemical causes of nausea.
• 30
  Which of these statements about hands is true?
  Difficulty: Easy     Topic: Signs in the hands 1
  a

  The most common cause for splinter haemorrhages is infective endocarditis

  b

  Bouchard’s nodes occur over the DIP joints in osteoarthritis

  c

  Heberden’s nodes occur over the DIP joints in rheumatoid arthritis

  d

  Gottron’s papules are pathognmonic of dermatomyositis

  e

  Mees’ lines are white nails seen in nephrotic syndrome
  Explanation: Gottron's papules are rough, red patches over the knuckles, elbows and knees. In the presence of raised CK they are pathognmonic of dermatomyositis. Trauma is the most common cause of splinter haemorrhages. Bouchard's nodes occur over the PIP joints and Heberden's nodes occur over the DIP joints; both are found in osteoarthritis. White nails are leukonychia, which are due to hypoalbuminaemia. Mees' lines are transverse white lines seen in renal failure.