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This course has been running since 1993 at the Hammersmith Hospital.

http://hammersmithmedicine.com

Medicine for finals: Monday 6th January 2014.

Taught by Karim Meeran

http://hammersmithmedicine.com

08.45 Registration and collect handouts.

09.00 Cardiology and ECG's.

11.15 Coffee

11.30 Respiratory Medicine

12.45 The Abdomen

13.15 Lunch

14.00 The abdomen (part 2)

14.30 Diabetes, Fundoscopy and Endocrinology

15.45 Tea

16.00 Neurology

17.00 Other miscellaneous conditions that commonly occur in finals.

17.30 Conclusions.

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Slide Quiz in Cardiology

1. This patient was an intravenous drug abuser. He died of a complication of his habit. What are the physical signs associated with this disease and what is the usual cause?

2. What is likely to be wrong with this lady who complains of exertional dyspnoea?

3. This is her chest X-ray. Give two abnormal features.

4. What is this rhythm? What are the causes?

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5. What is the diagnosis?

6. What is the diagnosis?

6a. What is the diagnosis?

6b. This is an inverted image of the ECG in Q6a.

7. A 47yr-old-man presents to casualty with severe central crushing chest pain. His ECG is shown. What is the diagnosis and what complication has occurred?

What are the main principles of management of this patient?

8. While you are examining him, his pulse rate falls to 30 per minute with a blood pressure of 70/40 mmHg. What needs to be done now?

9. Your management is successful, and he makes a good recovery. On the post take ward round the next day he complains of chest pain made worse by "a sharp intake of breath". The pain is also made worse by lying flat and radiates to his left shoulder. The pain is improved by his sitting forward. What treatment does he need now?

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10. This chest x-ray was taken from a patient complaining of chest pain. His only past medical history is of a myocardial infarction a year ago. The ECG is still abnormal.

a) What is the diagnosis?

b) What ECG changes will you see?

11. A 55yr-old-lady underwent a hysterectomy for an endometrial carcinoma. Ten days after the operation she suddenly developed chest pain and breathlessness. This is her pulmonary angiogram. What is the diagnosis?

11b) This is her ECG. What does it show?

12. What are the signs of heart failure?

12b. What is cardiogenic shock?

13. What are the indications for an exercise ECG? How is it carried out and what changes should one look for?

14. What is this rhythm ? What will you do ?

14b. This ECG was taken after the patient responded to treatment.

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Respiratory Quiz

1. This chest x-ray is from a 25 year old man who presented with a cough, a pyrexia and green sputum. What is the most likely diagnosis?

What signs will be apparent?

What investigations are essential?

What treatment will you give?

2. The above patient does not respond to your treatment. The next day he appears more unwell. He is pyrexial 41oC with warm peripheries. Pulse is 140 regular, BP=85/40. JVP is not visible.

What is he suffering from?

What treatment does he now need?

3. A 30 year old man collapses on the way back from X-ray. He had presented to casualty with sharp chest pains. The X-ray that was taken is shown. What is the diagnosis? What will you do?

4. What do you see?

What is the most likely cause of this appearance?

What is your differential diagnosis?

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5. What are the signs of CO2 retention (hypercapnoea)?

6. What is the management of acute severe asthma?

7. List the features of Pancoast's syndrome.

8. List the possible endocrine manifestations of lung cancer.

9. List the signs of obstructive airways.

10. List the signs of a pleural effusion.

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The Abdomen

1. What is the lesion shown in this photograph ?

1b. Where in the body may they be found ?

1c. What specific sign distinguishes them from other skin lesions ?

1d. What does the presence of this lesion suggest ?

1e. What other signs might you find on examination of this patient ?

2. This patient has normal sensation in his hands. He thus does not have an ulnar nerve palsy. What is the cause of this appearance ?

3. List the signs of portal hypertension.

4. List the causes of ascites.

5. In a jaundiced patient, how would you clinically distinguish obstructive from hepatitic jaundice?

6. A patient has a mass arising from the left upper quadrant of the abdomen. How would you clinically decide whether it was kidney or spleen?

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7. A 50 year old man complains of backache and feeling dizzy. On examination he is extremely pale. Pulse 140 regular, BP 80/40. JVP is not visible. He has cold, clammy peripheries. Abdominal examination reveals a pulsatile mass.

What is the likely diagnosis?

What treatment is needed?

8. What will this patient complain of?

9. List the causes of this condition.

10. Describe the lesions you can see.

11. List the causes of this condition.

12. Describe the signs you can see on this patients back.

13. What is the diagnosis?

14. What is the diagnosis?

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Diabetes

Answer true or false for the MCQ’s below:

1. Insulin:

a) Stimulates glucose uptake from blood into fat cells.

b) Stimulates glucose uptake from blood into muscle cells.

c) Stimulates the uptake of potassium and phosphate into cells.

d) When given intravenously causes a rise in plasma potassium.

e) Is a signal that you have just had a meal.

f) Suppresses ketone production by the liver.

2. The following characteristics are more likely to occur in type 1 than in Type II diabetes.

a) Dependence on insulin

b) Older patient

c) Concordance in identical twins

d) Obesity

e) Association with other autoimmune diseases

f) Hyperosmolar non-ketotic coma

3. A firm diagnosis of diabetes mellitus may be based on:

a) A random plasma glucose of 7.0 mmol/l

b) A fasting plasma glucose of 8.0 mmol/l

c) The presence of large amounts of glucose in the urine

d) A plasma glucose 2hours after food of 12 mmol/l

e) A plasma glucose of 9 mmol/l 2 hours after 75g glucose during

an oral glucose tolerence test

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4. In the treatment of severe hyperglycaemic ketoacidosis:

a) Potassium should not be given until the blood glucose is normal

b) If the blood pH is below 7.0, intravenous sodium bicarbonate

should be given

c) Bicarbonate should be given to elevate the blood pH to over 7.3

d) CSF pH rises in parallel to blood pH when bicarbonate is used

e) A high serum potassium before treatment indicates that

potassium depletion is not severe

f) Kussmaul respiration is a sign of severe metabolic acidosis and lowers pCO2

g) A nasogastric tube should be passed if there is impairment of consciousness

5. A woman of 72 years is admitted to hospital suffering from hyperosmolar diabetic coma. The following statements are likely to be true:

a) She is not known to have suffered from diabetes previously

b) Kussmaul respiration is prominent

c) The blood glucose is 28 mmol/l

d) The plasma sodium is over 160 mM

e) The sodium needs urgent correction.

Fundoscopy

1. List the stages of diabetic retinopathy.

What are the features of each stage?

2. List the grades of hypertensive retinopathy.

What are the features of each stage?

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3. What do you see?

What is the diagnosis?

4. What do you see?

What is the diagnosis?

5. What do you see?

What is the diagnosis?

6. What does this fundus show?

7. What do you see?

What further tests must be carried out?

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8. What is the diagnosis?

9. What is the diagnosis?

10. What will this patient complain of?

11.What is the diagnosis?

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Endocrinology

1. What does this slide show?

1b. List the clinical signs that you would expect to see.

1c. What features suggest activity ?

1d. What investigations should be performed?

1e. What three modalities of treatment are available?

2. What is the diagnosis?

2b. What signs suggest activity ?

2c. What important complication should you look for on examination?

2d. What investigations should be performed.

2e. What treatment is available?

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3. What is the diagnosis?

3b.What clinical signs of activity will you look for ?

3c. List the general complications of this condition.

3d. What tests should be performed?

3e. What treatment is available?

4. List two causes of adrenal failure

5. Why are these patients pigmented ?

6. What dynamic endocrine test is used to confirm the diagnosis ?

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7. A 70-year-old man complains of pain in his lower leg. He is noted to have a warm right tibia which was bowed.

What is the diagnosis?

What complications may occur ?

What investigations will you perform?

What treatment is available?

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Neurology

1. A child is admitted with a high fever, severe headache and a purpuric rash. What important test must be performed on the rash ?

He is photophobic and vomits in casualty. He also has a stiff neck.

His CT scan is shown. What is the most important next investigation?

What is the most likely diagnosis?

What treatment is required?

What other organisms can cause a similar clinical picture?

2. This 56 year old lady presented unconscious to casualty and had this CT scan. What abnormality do you see?

What is the likely diagnosis?

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3. This young man was hit on the head by a cricket ball. What is the diagnosis? What classical feature occurs in this condition?

4. This 50 year old alcoholic presented with confusion. What is the diagnosis?

5. What abnormalities can you see?

What is the diagnosis?

What are the causes?

6. What features distinguish an upper from a lower motor neurone lesion?

7. What are the features of Parkinson’s disease ?

8. What does this slide show?

9. What are the features of carpal tunnel syndrome?

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10. What clinical signs will make you look for a cerebellar lesion?

11. A 64y man presents with an expressive aphasia and right sided weakness. On examination he is found to have increased tone on the right hand side.

What is the most likely diagnosis?

What is your differential diagnosis?

What are you likely to find if you perform a full neurological examination?

12. A 35-year-old female complained of an episode of blindness which had got gradually worse over the preceding day. She attended her GP the following day by which time all her symptoms had resolved.

What signs should one look for ?

13. She remained well for a year but then developed numbness of her left leg and some weakness which got gradually worse over the following week.

What signs should you look for now and why (finish this page before turning over)?

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Examination revealed increased tone around the left ankle and knee with clonus. Power was reduced both in flexion and extension of her knee.

13b. What does this suggest ?

What are the possible causes ?

Examination of her upper limbs reveals normal tone and power. However she also has left sided dysdiadochokinesia.

What does this suggest?

What might you find on examination of her eye movements ?

What is the most likely underlying diagnosis ?

14. Describe what you see

What is the diagnosis ?

How is it inherited?

What complications can occur ?

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15. List the features of an Argyll Robertson Pupil

16. List the features of a Holmes-Adie myotonic pupil

17. List the features of a Marcus Gunn Pupil

For more questions, and also for details of future courses, see:

This course has been running since 1993 at the Hammersmith Hospital.

http://hammersmithmedicine.com

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Findings in patients with meningitis

Normal Acute purulent meningitis

Aseptic (viral) meningitis

Tuberculous meningitis

Appearance Clear Cloudy Usually clear Opalescent

Cells /mm3 0-5 lymphocytes

10-100,000 polymorphs

15-2000 lymphocytes

250-500 lymphocytes

Glucose 2.8 – 4.4 Low Normal Very low

Protein (g/l) 0.15 -0.35 0.5- 5.0 0.2 – 1.25 0.45 – 5.0

Features of shock

Cardiogenic Septic Hypovolaemic

Cause Heart failure Infection Bleeding

BP Low Low Low

JVP High Low Low

Peripheries Cold Warm Cold

Treatment Dobutamine Noradrenaline Blood