Signs: Reduced expansion, hyper-resonance to percussion and diminished breath sounds
on the affected side. With a tension pneumothorax, the trachea will be deviated away from the affected side
Management:
61. A pt with hepatocellular ca has raised levels of ferritin. What is the most probable cause?
a. Hemochromatosis b. A1 antitrypsin def
c. Cystic fibrosis
Ans. Haemochromatosis.
Haemochromatosis... Autosomal recessive.
SYMPTOMS bronzing of skin, DM, hepatomegly, arthropathy. Can also cause infertility, arrhythmias, neurological symptoms. Liver fibrosis, cirrhosis & HCC.
INVESTIGATIONS: Serum ferritin then genetic testing for HFE mutations.
TREATMENT: phlebotomy OR liver transplant
62. A woman has electric pains in her face that start with the jaw and move upwards.
Her corneal
reflexes are normal. What is the most likely dx?
a. Atypical face pain b. Trigeminal neuralgia
c. Tempero-mandibular joint dysfunction d. GCA
e. Herpes zoster Q. 1. What is the key?
Q. 2. What are the options mentioned are possible causes of absent corneal reflex?
Ans. 1. Key is b. Trigeminal neuralgia.
Ans. 2. Possible options are 1. Trigeminal neuralgia 2. Herpes zoster ophthalmicus Trigerminal Neuralgia...Facial pains. PRESENTATION: The episodes are sporadic and sudden and often like 'electric shocks', lasting from a few seconds to several minutes.
Pain is unilateral, brief, stabbing, recurrent in the distribution of CN5. Can be provoked by light touch to the face, eating, cold winds, or vibrations typically occurs after shaving, brushing teeth.
Cause is a compression of CN5.
No Investigations
TREATMENT: Carbamezapine is the first line. Rhizotomy (surgery) may also be done 63. A 32yo man presented with slow progressive dysphagia. There is past hx of retro-sternal
discomfort and he has been treated with prokinetics and H2 blockers. What is the probably dx?
a. Foreign body
b. Plummer vinson syndrome c. Pharyngeal pouch
d. Peptic stricture e. Esophageal Ca Q. 1. What is the key?
Q. 2. What is the underlying cause of this stricture?
Ans. 1. The key is D. Peptic stricture.
Ans. 2. The underlying cause is Gastro-oesophageal reflux.
Points not in favor of CA: Age (32yrs), no anemia, anorexia, lethargy etc mentioned.
Peptic Stricture
PRESENTATION: heartburn, dysphagia, impaction of food, weight loss, and chest pain.
There can be progressive dysphagia, weight loss & anemia.
CAUSES: History of GERD, corrosive intake, drugs like NSAIDs INVESTIGATIONS: Endoscopy (risk of perforation) Barium swallow
TREATMENT: Benign: endoscopic baloon dilation. Malignant: oesophagectomy
64. A 56yo man comes with hx of right sided weakness & left sided visual loss. Where is the
Q. 2. How will you differentiate between middle cerebral artery occlusion from anterior cerebral artery occlusion?
Ans. 1. The key is d. Carotid artery.
Ans. 2.
i) Middle cerebral artery occlusion: paralysis or weakness of contralateral
face and arm (faciobracheal). Sensory loss of the contralateral face and arm.
ii) Anterior cerebral artery occlusion: paralysis or weakness of the
contralateral foot and leg. Sensory loss at the contralateral foot and leg.
Carotid Artery occlusion:
PRESENTATION: Patients may present with TIAs or CVEs.
Typical symptoms are contralateral weakness or sensory disturbance, ipsilateral blindness, and (if the dominant hemisphere is involved) dysphasia, aphasia or speech apraxia.
Carotid bruit may or may not be present
INVESTIGATIONS: For diagnosis: CAROTID ANGIOGRAPHY GOLD STANDARD. MR angio and angio CT can also be used.
Echo colour Doppler ultrasonography is the screening method of choice TREATMENT: Medical: Antiplatelets, Anti HTN, Statins
Surgery: Carotid endartarectomy. Symptomatic patients with greater than 50% stenosis and healthy, asymptomatic patients with greater than 60% stenosis warrant
consideration for carotid endarterectomy.
65. A young college student is found in his dorm unconscious. He has tachyarrhythmia and high
fever. He also seems to be bleeding from his nose, which on examination shows a perforated
nasal septum. What is the most likely dx?
a. Marijuana OD b. Cocaine OD c. Heroin OD d. Alcohol OD e. CO poisoning
Q. 1. What is the key?
Q. 2. What are the points that favours the diagnosis in given question?
Q. 3. What are other important findings?
Ans. 1. Key is B. Cocaine overdose.
Ans. 2. Points in favour: i) Tachyrhythmia ii) High fever iii) perforated nasal septum iv) unconsciousness
Ans. 3. Other findings: i) Psychiatric: anxiety, paranoia ii) Tachypnoea iii) Increased energy and talking rapidly iv) Dilated pupils. Also: [rhabdomyolysis, metabolic acidosis, convulsion].
COCAINE… may be snored, taken via IV or smoked.
PRESENTATION: occasional use produces euphoria, increased alertness and feelings of self-confidence and competence
frequent repeated use causes tachycardia, twitching, insomnia and anxiety ADDICTION: can result in perforated nasal septum, psych problems.
The patient may present in anxiety, paranoia, they may ask for help.
MANAGEMENT: CBT, self help groups. Benzodiazepines are first line drugs, anti depressents like SSRIs but donot use with cocaine (causes SSRI syndrome). Beta blockers for anxiety
66. A 56yo pt whose pain was relieved by oral Morphine, now presents with progressively
worsening pain relieved by increasing the dose of oral morphine. However, the pt complains
that the increased morphine makes him drowsy and his is unable to carry out his daily activities.
What is the next step in his management?
a. Oral oxycodone b. Oral tramadol c. PCA
d. IV Fentanyl e. Diamorphine
Ans. Key is oral oxycodon.
If there are intolerable side effects to morphine go for oral oxycodone Pain ladder: NSAIDs, Mild opioids, strong opioids.
Once on one step of the ladder do not go back.
NSAIDs are good for bone pain.
Morphine Start with oral solution 5–10mg/4h PO with an equal breakthrough dose as often as required. A double dose at bedtime can enable a good night’s sleep. Patient needs will vary greatly and there is no maximum dose; aim to control symptoms
with minimum side-effects. If not effective, increase doses in 30–50% increments (5mg10mg20mg30mg45mg). Change to modified release preparations (eg
MST Continus® 12h) once daily needs are known by totalling 24h use and dividing by 2. Prescribe 1/6th of the total daily dose as oral solution for breakthrough pain. Sideeff ects (common) are drowsiness, nausea/vomiting, constipation and dry mouth.
Hallucinations and myoclonic jerks are signs of toxicity and should prompt dose review.
If the oral route is unavailable try morphine/diamorphine IV/SC (see BOX for
conversions). If difficulty tolerating morphine/diamorphine, try oxycodone PO/IV/SC/
PR, starting at an equivalent dose. It is as effective as morphine and is a useful 2nd-line
opioid with a different range of receptor activity. 61 OxyNorm® is the oral liquid form.
There are also fentanyl transdermal patches which should usually be started under specialist supervision (after opioid dose requirements have been established). Remove after 72h, and place a new patch at a different site. 45mg oral morphine/24h
is approximately equivalent to a 12mcg/h fentanyl patch.
67. A 30yo man presents with a 5cm neck mass anterior to the sternocleido-mastoid muscle on the left side in its upper third. He states that the swelling has been treated with antibiotics for
infection in the past. What’s the most likely cause?
a. Branchial cyst
Q. 2. Justify your answer.
Ans. 1. The key is A. Branchial cyst.
Ans. 2. i) Branchial cyst is anterior triangular lump. [parotid is also anterior triangular lump but it regresses with appropriate treatment]. ii) pharyngeal pouch is posterior triangular lump. iii) Thyroglossal is midline lump. iv) thyroid swelling moves with swallowing.
Branchial cysts emerge under the anterior border of sternocleidomastoid where the upper third meets the middle third (age <20yrs).
CAUSE: Due to non-disappearance of the cervical sinus (where 2nd branchial arch grows down over 3rd and 4th)
TREAT by excision
•If lump in the supero-posterior area of the anterior triangle, is it a parotid tumour 68. An 18yo man is rushed into the ER by his friends who left him immediately before they could be interviewed by staff. He is semiconscious, RR=8/min, BP=120/70mmHg, pulse=60bpm. He is
noted to have needle track marks on his arms and his pupils are small. What is the single best
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of the diagnosis?
Ans.1. The key is B. Naloxone.
Ans. 2. The diagnosis is opiate overdose.
Ans. 3. Points in favour are: i) reduced consciousness ii) RR 8/min (12<) iii) hypotension (here lower normal) iv) miosis v) needle track marks on his arms.
Opioid overdose presents with the usual Adverse effects of opioids. This is a typical presentation. Treatment IS WITH NALOXONE IV/IM/SC
OPIOID WITHDRAWAL SYMPTOMS:
Sweating. Watering eyes. Rhinorrhoea Yawning Feeling hot and cold. Anorexia and abdominal cramps. Nausea, vomiting and diarrhoea. Tremor. Insomnia, restlessness, anxiety and irritability. Generalised aches and pains. Tachycardia, hypertension. Goose flesh (goosebumps). Dilated pupils. Increased bowel sounds. Coughing.
COMPLICATIONS: Skin infection at injection sites (can be severe; necrotising fasciitis can occur). Septicaemia. Infective endocarditis. HIV infection. Hepatitis A, B and C infection. Tuberculosis infection.
TREATMENT: Methadone or buprenorphine. Stabilize the patient on either of the two.
Naltrexone can be used once the patient is detoxified.
69. A 30yo man and wife present to the reproductive endocrine clinic because of infertility. The man is tall, has bilateral gynecomastia. Examination of the testes reveals bilateral small, firm testes.
Which of the following inv is most helpful in dx?
a. CT of pituitary
b. Chromosomal analysis
c. Measure of serum gonadotropins d. Measure of serum testosterone Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of your diagnosis?
Ans. 1. The key is B. Chromosomal analysis.
Ans. 2. The diagnosis is Klinefelter’s syndrome. (xxy)
Ans. 3. The points in favour are: i) Infertility ii) Tall stature iii) Bilateral gynaecomastia iv) Bilateral small firm testes.
Klinefelter’s syndrome: (47,XXY, 48,XXYY polysomy or a mosaic 47,XXY/46,XY) Turner’s is XO with NO Barr body.
PRESENTATION: Infertility & small testis (most common & most imp) gynecomastia, lack of secondary sexual characteristics, tall and slender and learning disablities (delayed speech, behavioral problems)
Investigations: Before birth via amniocentesis or CVS.
Later serum testosterone is low. FSH & LH are high (FSH>LH) Chromosome karyotyping gives the deifinitive diagnosis
TREATMENT: 1. Testosterone replacement. 2.Intracytoplasmic injection of sperm. 3.
Surgery for gynecomastia
70. An 18yo female just received her A-Level results and she didn’t get into the university of her
choice. She was brought into the ED after ingestion of 24 paracetamol tablets. Exam:
confused
and tired. Initial management has been done. Inv after 24h: normal CBC, ABG = pH7.1, PT=17s,
Bilirubin=4umol/L, creatinine=83umol/L. What is the next step in management?
a. Observation for another 24h b. Refer to psychologist
c. Give N-Acetylcysteine
d. Discharge with psychiatry referral e. Liver transplantation
Q. 1. What is the key?
Q. 2. What are the indications of this management?
Ans. 1. The key is E. Liver transplantation.
Ans. 2. King's College Hospital criteria for liver transplantation in paracetamol-induced acute liver failure.
arterial pH <7.3 or arterial lactate >3.0 mmol/L after adequate fluid resuscitation, OR if all three of the following occur in a 24-hour period:
Creatinine >300 μmol/L.
PT >100 seconds (INR >6.5).
Grade III/IV encephalopathy.
PARACETAMOL POISONING: >150mg/kg or 12g total
PRESENTATION: Hepatic damage shown by deranged LFTs occurs after 24hrs.
Patients may develop encaph, hypoglycemia, ARF
INVESTIGATIONS: Paracetamol levels: 4hrs post ingestion, if time is >4hr or staggered overdose
Any alcohol taken (acute alcohol ingestion will inhibit liver enzymes and may reduce the production of the toxin NAPQI, whereas chronic alcoholism may increase it)
MANAGEMENT:
If presentation is within the first 4 hours give activated charcoal
All patients who have a timed plasma paracetamol level plotted on or above the line drawn between 100 mg/L at 4 hours and 15 mg/L at 15 hours after ingestion, should receive acetylcysteine.
If time unknown (even in staggered dose) give N-Acetyl cysteine without delay
NAC most effective in the first 8 hrs.
NAC can be given during pregnancy
Beware if the patient is on any P450 enzyme inducer medicines as they increase the toxicity
Refer to ICU if there is fulminant liver failure - those treated with N-acetylcysteine (NAC) to the medical team and all para-suicides to the psychiatric team.
71. A 75yo alcoholic presents with a mass up to umbilicus, urinary dribbling, incontinence, and
clothes smelling of ammonia. What is the next step in management?
a. Urethral catheter
Q. 2. What is the cause of this retention?
Ans. 1. The key is A. Urethral catheter.
Ans. 2. Alcohol consumption (it is rather a less common cause of urinary retention).
ACUTE URINARY RETENTION