116 - miscellaneous 8 bits

Theme:Psychiatric disorders in pregnancy and the puerperium

A'baby blues'
BChronic schizophrenia
CDepressive illness
DMunchausen's disease
ENeurotic Disorder
FPersonality disorder
GPhobic disorder
HPostnatal depression
IPostpartum thyroiditis
JPuerperal psychosis
KSheehan's syndrome

For each of the following clinical scenarios, select the most appropriate diagnosis from the list of options:

A 27-year-old woman, 2 days following the normal vaginal delivery of her second child, is found sobbing uncontrollably at home by her husband. She has been coping well otherwise.

The correct answer is 'baby blues'

Baby blues is a normal phenomenom, occurring in up to 30% of women. It normally recovers within 72 hours, is characterised by tearfulness but no loss in sense of reality. It is thought to be due to rapid changes in endocrine hormone profiles, particularly oestrogen and progesterone. It is a self limiting condition.

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A 32-year-old 6 weeks following the vaginal delivery of her 5th child, which was complicated by a large postpartum haemorrhage, presents to her general practitioner complaining of lethargy, loss of libido and difficulty in bonding with her new baby. She looks extremely pale although her haemoglobin is normal.

SHEEHAN'S SYNDROME.

Sheehan's syndrome follows ischaemic destruction of the pituitary, classically after hypotension secondary to major blood loss. Its features are often masked because of the physiological changes in the puerperium and are variable depending on the degree of pituitary destruction. Classically, the symptoms are due to reduced ACTH production which causes lethargy, inability to cope with stress and emotional blunting. Extreme pallor is often a feature.

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A 19-year-old living alone, 2 weeks following the delivery of her first child complains of difficulty sleeping, tearfulness and anxiety that she is incapable of looking after her baby.

The correct answer is Postnatal depression

Risk factors for postnatal depression are: single, young, chronic life difficulties, social adversity and past history of psychiatric illness.

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A 36-year-old solicitor, 3 days after an emergency Caeserean Section for fetal distress, suddenly becomes aggressive and abusive to staff and her partner. She threatens to strangle her baby.

PUERPERAL PSYCHOSIS

Puerperal psychosis is characterised by a sudden presentation of aggressive, out of character behaviour in the first 5 days post-natally. This behavious may include threats to harm herself, partner or the baby.

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A socially withdrawn 42-year-old, living alone presents to the antenatal clinic at 26 weeks with dishevelled appearance and exhibiting poor personal hygiene. Prior to this visit, she has not attended for antenatal care and is unresponsive throughout the interview, failing to make any eye contact.

The correct answer is Chronic schizophrenia

This woman illustrates many of the typical features of schizophrenia, namely social isolation, blunted affect and little interest in personal appearance or hygiene.

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A 27 year-old female presents with a 3 hour history of vaginal bleeding, abdominal pain and right shoulder tip pain. Her past history includes pelvic inflammatory disease, a miscarriage and two terminations. A urine pregnancy test is positive.

From the following which is the most appropriate next step of management?

1.Admit as an emergency under the gynaecologists.
2.Prescribe analgesics and review in 24 hours.
3.Refer for routine ante-natal clinic
4.Treat for a possible sexually transmitted disease with clarithromycin and ciprofloxacin
5.Take high vaginal swabs nd review with results in 48 hours.

answer is 1 .

This history should alert you to a possible diagnosis of n ectopic pregnancy with risk factors being the PID, previous terminations and the positive pregnancy test. This is a gynaecological emergency and requires emergency admission.

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Regarding intertrochanteric fractures of the femur:

True / False
They are more likely to cause avascular necrosis of the femoral head than intracapsular femoral head fractures - FALSE
They are treated with femoral head replacement in most cases - FALSE
They can be treated with dynamic hip screw (DHS) fixation - TRUE
They can cause the leg to be adducted - TRUE
They typically cause shortening and internal rotation of the leg - FALSE

Intracapsular (neck of femur) fractures of the femoral neck are more likely to cause severe damage to the blood supply of the femoral head than intertrochanteric fractures. The leg us usually shortened and externally rotated. It may be adducted because intertrochanteric fractures separate abductors from adductors across the fracture line. DHS is the commonest method of fixation.

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You are called to see a patient on the ward who is short of breath and complaining of chest pain. She has recently had a sigmoid colectomy for bowel cancer. You suspect she might have had a pulmonary embolism. An ECG has been performed. Which of the following are typical ECG findings in pulmonary embolism:

Bradycardia
RIGHT bundle branch block - TRUE
S3Q3T3
S1Q3T3---------- TRUE
Tacycardia - TRUE

ECG changes usually only occur with large pulmonary emboli. The characteristic changes include tachycardia, a right ventricular strain pattern with inverted T waves in V1-V4, right bundle branch block, S1Q3T3 pattern and transient arrhythmias, such as atrial fibrillation.

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Theme:Thyroid disease

AGraves Disease
BMultinodular goitre
CThyroiditis
DThyroxine overdose
EToxic thyroid adenoma

In the following cases, select the most likely diagnosis:

Normal ranges
T4 9-22
T3 3.5-5.5
TSH 0.35-5

A 56-year-old housewife presents with weight loss, sweating and a goitre. Clinical examination reveals a heart rate of 100bpm, a moderate goitre with no retrosternal extension. Examination of the eyes reveals lid retraction and lid lag. Free T4 is 36.7 pmol/l and TSH <>

TOXIC THYROID ADENOMA
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A 35-year-old man who works as a taxi driver presents with a 3 month history of palpitations, sweating and a goitre. Clinical examination reveals a heart rate of 60bpm, a small painless goitre and no evidence of hyperthyroidism. His tests show free T4 8 pmol/l and TSH of 16 mlU/l (NR 0.3-4.5). Thyroid peroxidase antibodies are positive.

THYROIDITIS
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A 17-year-old lady who works in a chemist presents with a 6 month history of sweating excessively when exercising in the gym. Clinical examination reveals a heart rate of 120bpm, lid retraction and lid lag. No goitre is palpable. Free T4 is 28 pmol/l and TSH <>

THYROXINE OVERDOSE
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The woman has thyrotoxicosis with increased focal uptake on uptake scintigraphy indicating a toxic adenoma. The 35-year-old male has hypothyroidism most likely due to a Hashimoto’s thyroiditis. The 17-year-old female has thyrotoxicosis and this is due to excessive intake of exogenous thyroxine as there is no uptake of Radio-iodine indicating that the gland is suppressed.

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The spinal cord:

True / False
Is continuous above with the medulla oblongata ---------TRUE
Is intimately related to the pia mater throughout its course-------TRUE
The arachnoid membrane terminates at the level of second lumbar vertebra ----TRUE
A spinal segment consists of both anterior and posterior nerve roots------------TRUE
Receives blood supply from the vertebral arteries------------ TRUE

At the upper border of the atlas, the spinal cord is directly continuous with the medulla oblongata. Inferiorly, the cord usually extends as far as the first lumbar intervertebral disc where it terminates as the conus medullaris. The pia mater is a highly vascular layer which closely invests the spinal cord and nerves, and surrounds the termination of the spinal cord (conus medullaris) and continues as the filum terminale as far as the posterior surface of the coccyx. The arachnoid membrane is continuous with the cranial arachnoid through the foramen magnum and below, it ends at the level of the second sacral vertebra. The spinal nerves are attached to the spinal cord by anterior and posterior nerve roots. The region of the spinal cord to which one pair of anterior and posterior nerve root attaches is called a spinal segment. The spinal cord receives its arterial supply from the anterior and posterior spinal arteries which arise from the vertebral arteries and are reinforced by branches of deep cervical, intercostal and lumbar arteries.

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Theme:Thyroid Cancer

AAnaplastic carcinoma
BFollicular adenoma
CFollicular carcinoma
DLymphoma
EMedullary thyroid carcinoma (MTC)
FPapillary carcinoma

For each patient described below, select the most likely single diagnosis from the list of options above. Each option may be used once, more than once or not at all.

A 16-year-old girl presents to the surgical outpatient department with a neck swelling. Clinical examination shows a 2.8cm solid lump in the left thyroid lobe and two enlarged cervical lymph nodes lateral to the thyroid mass. Ultrasonography confirms the solid nature of the thyroid nodule. FNA biopsy of the thyroid nodule reveals malignant cells with vesicular appearance of nuclei. The nodule is cold on radio-isotope scanning.

PAPILLARY CARCINOMA OF THYROID
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A 70-year-old man presents to OPD with a rapidaly enlarged thyroid swelling and hoarseness. Clinical examination shows a 2.8cm solid lump in the left thyroid lobe and two enlarged cervical lymph nodes lateral to the thyroid mass. Ultrasonography confirms the solid nature of the thyroid nodule. FNA biopsy of the thyroid nodule reveals malignant cells with vesicular appearance of nuclei. The nodule is cold on radio-isotope scan.

ANAPLASTIC CARCINOMA OF THE THYROID
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The young girl has a thyroid cancer most likely to be a papillary carcinoma as suggested by age alone and this contrasts with the male who with local invasion and again the later age would be more typical of a anaplastic lesion.

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In HIV, the following are correct

True / False
All patients with a CD4+ count of <500>
Aspergillus is the most common cause of fungal brain disease - FALSE
Co-trimoxazole is the treatment of choice for Pneumocystis carinii pneumonia - TRUE
Opportunistic infections normally occur with a CD4 count > 200 cells/mm3 - FALSE
Pneumocystis carinii pneumonia can present with a normal chest x-ray - TRUE

a)Ambiguous question. The cut off is stated as <200>
b)Cryptococcocal meningitis is the most common.
c)It is also used as a prophylaxis agent in HIV patients at risk from PCP.
d)Normally <200>
e)Up to 25% of patients can have a normal appearance initially.

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Your consultant suspects a patient on the ward might have amyloidosis. Which of the following tests would diagnose this disease?

1.Abdominal ultrasound
2.ECG
3.Echocardiogram
4.Tissue or organ biopsy
5.Urinalysis

4 IS THE RIGHT ANSWER .

Diagnosis of amyloidosis is based on finding amyloid deposits in organs or other body tissues. Biopsies are typically taken from the rectum, abdominal fat or bone marrow under local anaesthesia. Only bone marrow tests or biopsies of tissue can positively establish the diagnosis of amyloidosis and classify the type. However, there may be abnormalities in the other tests listed above depending on the organs affected.

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The adductor canal

True / False
contains an artery which contributes to the genicular anastomosis TRUE
contains a nerve supplying the tensor fascia lata muscle FALSE
contains the deep femoral artery FALSE
contains the nerve to the vastus medialis muscleTRUE
contains the saphenous nerve TRUE

The adductor canal is a gutter shaped groove between the vastus medialis muscle and in front of the adductor muscle. The gutter is roofed by the sartorius muscle, underneath which a fascia contains the subsartorial plexus. The canal transmits the femoral artery and vein, saphenous nerve and, in the upper part, the nerve to the vastus medialis muscle. The tensor fascia lata muscle is supplied by the superior gluteal nerve (L4, L5, S1), which crosses the buttock and ends in the muscle.

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Theme:Calcium disorders

ABisophosphonate treatment
BCalcitonin
CExplortation and parathyroidectomy
DNo action required
ERehydration with 0.9% saline

Select the most appropriate treatment for the following cases:

Normal ranges
Calcium 2.2-2.6
PTH 3-7

A 55-year-old man presents with recurrent renal stones. Investigation has revealed a calcium of 2.70 mmol/l corrected for albumin. His PTH is 10pmol/l. 24 hour urinary excretion of calcium is 12 mmol/24 hours (NR 2.5-7.5 mmol/24 hours). Ultrasound of the neck did not detect any sign of a parathyroid adenoma. SestaMIBI scan is inconclusive.

The correct answer is Explortation and parathyroidectomy.

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A 60-year-old female is referred to your clinic for an incidental finding of corrected hypercalcaemia: 2.8 mmol/l. Her PTH is 7.1 pmol. 24 hour urinary excretion of calcium is 1.7 mmol/24 hours (NR 2.5-7.5 mmol/24 hours). SestaMIBI scan of the neck has detected a possible adenoma posterior to the left lower pole of the thyroid.

The correct answer is No action required.

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A 70-year-old female on the orthopaedic ward who has been admitted today with a right neck of femur fracture. She is confused and her calcium result is 2.9 mmol/l corrected.

The correct answer is Rehydration with 0.9% saline

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You have just admitted a 75-year-old lady with a painful vertebral crush fracture of the 10th thoracic vertebra. She has a calcium of 2.53 mmol/l corrected.

The correct answer is Bisophosphonate treatment.

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The 55-year-old male has hypercalcaemia and high PTH with hypercalciuria indicating primary hyperPTH. The most appropriate treatment would be surgery. The 60-year-old female has mild hypercalcaemia but a normal PTH (this would be inappropriately normal and still could reflect hyperPTH) but her urine calcium is low and this would suggest Familial Hypocalciuric Hypercalcaemia – no treatment is required. The elderly female with a fractured NOF needs rehydration first and then investigation to establish the cause of the hypercalcaemia. The 75-year-old female has a normal calcium concentration but has what appears to be a osteoporotic fracture for which bisphosphonates would be most appropriate.

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Concerning fluoroscopy:

True / False
Effective dose is estimated using a dose area product meter - TRUE
A dose area product meter is attached below the patient when using over couch - FALSE
Effective dose is the sum of the weighted equivalent doses for all the tissues - TRUE
Male gonad dose can be estimated by attaching a TLD to the scrotum - TRUE
The Health and Safety Executive and Healthcare Commission must be informed if the actual exposure is greater than 1.5 times intendeD- FALSE

The DAP meter is mounted on the light beam diaphragm.

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Theme:Psychopathology

APalinopsia
BHypnagogic hallucination
CExtra campine hallucination
DVisual hallucination
EHaptic hallucination
FReflex hallucination
GAutoscopy
HIllusion
ISynaesthesia
JCharles Bonnet Syndrome

For each of the following cases, choose the most likely option from the above list

A 45-year-old woman who claims to see the trace of objects as they move around.

The correct answer is Palinopsia

Palinopsia is a phenomenon in which there is perseveration of a visual sensation. Palinacousis is ictal phenomenon with perseveration of an auditory sensation.

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A 37-year-old woman who claims that she hears the colour red when she sees it.

The correct answer is Synaesthesia

In synaesthesia the sensory stimulus in one modality is perceived as a sensation in another modality.

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A 60-year-old man with bilateral cataracts, otherwise healthy, says he sees things that he could not explain.

Charles Bonnet syndrome.

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Sometimes visual hallucinations do not appear to be associated with other psychiatric abnormality. Phantom visual images is a condition in which individuals experience complex visual hallucinations with a demonstrable psychopathology. This is known as Charles Bonnet syndrome.

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q-In confabulation there are fragments of preserved memory- true

Confabulation is a falsification of memory occurring in clear consciousness in association with an organically derived amnesia. Confabulation is a major feature in Korsakoff’s syndrome but is not diagnostic of the condition. Fragments of memory though are preserved around which convincing stories can be constructed.

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