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Mixed Medicine/Surgery Questions
Ian Anderson
19/03/2007
What is this condition?
What pattern of inheritance does it have?
What problems would this patient be at increased risk of?
What are these lesions?
List four conditions that they might be a sign of.
What abnormality is present in this man (his bruises are from Clexane injections)
What is the diagnosis? What is THE MOST LIKELY cause of this?
How much Clexane prophylaxis would this man receive on a) a medical ward b) a surgical ward?
1.
2.
3.
Name these lesions and suggest the
underlying cause for them
A) Non-tender, highly
mobile lump
B) Vague edges, pain on
examination
What is the most likely
diagnosis of these three
breast lumps?
Which is the odd one out?
Why?
•What procedure
is being
performed in this
image?
•For what
condition is this
operation
performed?
•What are the
common
symptoms?
•What nonsurgical
treatments might
this patient have
previously tried?
What is the abnormality in this chest film?
What conditions is this abnormality associated with?
What is this skin eruption?
Give four conditions that it is associated with.
What abnormalities are present? What is your diagnosis?
Question 1
• Osler-Weber-Rendu syndrome (hereditary
haemorrhagic telangectasia)
• Autosomal dominant
• Epistaxis
GI bleeds
AV malformation (which may cause high
output cardiac failure and increased stroke
risk)
Question2
• Splinter haemorrhages
• Trauma (esp manual labour)
Infective endocarditis
Trichinella spiralis infestation
Vasculitides (e.g. RA, SLE, PAN)
Sepsis
Haematological malignancy
Severe anaemia
Question 3
•
•
•
Tortuous, dilated veins of the abdomen, especially through the
central, epigastric region. They do not radiate from the
umbilicus and therefore caput medusa is incorrect here
Inferior vena cava obstruction. The most common cause of
IVC obstruction is a malignant tumour spreading from one of
the abdominal viscera. If the tube in the picture is a
nephrostomy, then perhaps this is renal in origin but it may
well just be an IV infusion line from a cannula in his hand
Medical patients all get 40mg(4000 units)/24h of clexane and
surgical patients all get 20mg(2000 units)/24h. [Other doses:
DVT treatment is 1.5mg/kg/24h, unstable angina/NSTEMI
get 1mg/kg/12h] NB: Clexane is not a generic name and
should technically be prescribed as “enoxaparin sodium” on
a drug chart.
Other Causes of IVC Obstruction
• Thrombosis (For example, in individuals with polycythaemia or
congenital clotting disorders, such as factor V Leiden and
deficiencies in protein C, protein S, or antithrombin III)
• Liver or pancreatic disease
• Lymphadenopoathy of paravertebral peritoneal lymph nodes
• Fibrous adhesions (These are common in individuals who have
had previous abdominal surgery)
• Aortic aneurysm (Which is thought in some cases to press
directly on the vessel)
• Congenital
• Embolism
• Iatrogenic (For example, accidental surgical clamping)
Question 4
1. Janeway lesions: Janeway lesions are painless
palmar macules seen in patients with infective
endocarditis.
2. Syphilids (i.e. Cutaneous secondary syphilitic
lesions on palms or soles): These are due to
treponema pallidum infection (a spirochaete).
These lesions occur ~6-8 weeks after the development of a primary chancre in 80% of cases.
They are symmetrical, generalized, superficial, non-destructive, transient lesions. They may be
macular intially but become papular and more tender with time. Lesions are usually found on the
face, shoulders, flank, palms and soles, and anal or genital regions. Individual lesions are
generally <1 cm in diameter.
3. Tophi: these are due to gout/pseudogout.
If you really wanted to you can do an aspiration and polarized light examination of
the synovial fluid - shows negatively birefringent crystals in true gout.
Question 5
A. Fibroadenoma. Common in young adults.
Usually a discrete mass, often in the
superio-medial quadrant of the breast.
These are thought to be due to increased
oestrogen sensitivity. Not commonly
excised if <4cm. Can do FNAC although
opinion differs (I fucking well would
anyway!)
Question 6
• Vitiligo is the odd one out (bottom right)
• Conjuctivitis, urethritis (shown here with a
discharge) and seronegative arthritis are
three cardinal features of Reiter’s syndrome
• NB: The two commonest causes of Reiter’s
syndrome are genital (chlamydia &
gonorrhoea) and enteric (salmonella,
yersinia, shigella & campylobacter)
Question 7
• Nissen fundoplication
• Hiatus hernia
• 50% are asymptomatic. Other symptoms include: reflux
oesophagitis, dysphagia, duodenal or gastric ulcer,
regurgitation of food at night, hiccough, nausea and
vomiting & waterbrash. It is associated with gallstones and
diverticular disease (Saint’s triad).
• Conservative management: Don’t lie down before meals,
eat small meals, don’t eat before bed, sleep with head
elevated, stop smoking
Drug management: PPIs, H2 antagonists (in severe cases
only), antacids may be helpful, no benefit in H. Pylori
eradication therapy.
Question 8
• Widened mediastinum (probably dissecting AA)
• Causes (in order of commonness):
Hypertension (90% of cases)
Collagen diseases (e.g. Marfan’s)
Pregnancy
Bicuspid aortic valve
Coarctation of the aorta
Aortic surgery
Trauma
Question 9
•
Erythema nodosum
•
•
Sarcoidosis (30 to 40% of cases)
Infectious causes:
–
–
–
–
–
streptococcal/viral throat infections - most common
chlamydia - relatively common
tuberculosis - relatively common
mycoplasma
yersinosis - more common in non-UK European countries
•
•
Inflammatory bowel disease:
–
–
Crohn's
Ulcerative colitis
•
•
Sulphonamides
Oral contraceptive pill
Malignancy:
–
•
•
•
Rarely, Behcet's disease
Drugs are a common cause:
–
–
•
Rarely, histoplasmosis, leprosy, psittacosis, cat-scratch disease, lymphogranuloma venereum
Lymphoma, leukaemia
Post-radiation therapy
Pregnancy
Often no cause is found
Question 10
Pre-proliferative diabetic retinopathy: