Download Back To The Old School

BACK TO THE OLD SCHOOL
QUESTION 1.


(a)
(b)
(c)
(d)
(e)
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?
gastro-oesophageal reflux disease
duodenal atresia
pyloric stenosis
UTI
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 nonblanching 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 anticardiolipin 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
B
C
D
E

Duct papilloma
Fat necrosis
Duct ectasia
Fibroadenoma
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
B
C
D
E

Viral Meningitis
IgA Nephropathy
Henoch Schönlein Purpura
Idiopathic thrombocytopenic purpura (ITP)
Kawasaki's disease
QUESTION 14

Which of the following signs are not associated
with severe pulmonary hypertension?
A
B
C
D


E
Hepatomegaly
Right ventricular heave
Large V waves in the JVP
Pan-systolic murmur loudest at the lower left
sternal edge in expiration
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 nonblanching purpuric rash on his legs. What
diagnosis would be your primary concern?
A
B
Thrombocytopenic purpura
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 selflimiting, 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 anticardiolipin 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 inferoposterior 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

E
Pan-systolic murmur loudest at the lower left
sternal edge in expiration
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
B
C

D

E


Chronic migraine
Paroxysmal hemicrania
Short lasting unilateral neuralgiform headache with
conjunctival injection and tearing
Cluster headache
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.