1. A 60 year old Caucasian woman, not normally prone to headaches, describes the gradual onset of worsening pain over the left side of her head, during the last five days. It is jabbing in nature and is aggravated by combing her hair. She has also noticed pain in the jaw when eating or talking. She has no rash. What is the single most likely diagnosis?
a ) Acute closed-angle glaucoma
b ) Migraine
c ) Retinal artery occlusion
d ) Temporal arteritis
e ) Trigeminal neuralgia
Answer: D
Temporal arteritis is 4-6 times more common in women than in men. It affects mainly those over the age of 50 – increasing with age. Jaw claudication occurs in approximately 65% of patients with temporal arteritis. Prompt treatment with oral steroids is required as more than 50% of untreated patients will get visual loss.
2. A patient presents to you in the surgery with several articles about his condition which he has taken from the internet. He wishes your opinion about the scientific robustness of these studies. You agree to read them in your spare time and report back to him. Which one of the following methods would you weight most highly in basing your opinion?
a ) Case control study
b ) Cohort study
c ) Expert opinion
d ) Meta-analysis
e ) Randomised control study
Answer: D
Meta-analysis is the systematic review of Randomised Control Trials. This is the highest level of evidence.
Levels of Evidence
Level
1++
High quality meta analysis, systemic review of RCTs, or RCTs with a very low risk of bias
1+
Well conducted meta analysis, systemic review of RCTs, or RCTs with a low risk of bias
1-
Meta analysis, systemic reviews of RCTs, or RCTs with a high risk of bias
2++
High quality systemic reviews of case-control or cohort studies.
High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is casual.
2+
Well conducted case control or cohort study with a low risk of confounding, bias, or chance and a moderate probability that the relationship is casual.
2-
Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not casual.
3
Non-analytical studies, e.g. case report, case series
4
Expert opinion
Grades Of Recommendation
Grade
A
At least one meta analysis, systemic review, or RCT rated as 1++, and directly applicable to the target population: or
A systemic review of RCTs or a body of evidence consisting principally of studies rated as 1+ , directly applicable to the target population, and demonstrating overall consistency of results
B
A body of evidence including studies rated as 2++, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C
A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4; or
Extrapolation of evidence from studies rated as 2+
3. OPTIONS:
a ) Adrenal Carcinoma
b ) Colonic Carcinoma
c ) Gastric Carcinoma
d ) Hodgkin’s Lymphoma
e ) Pancreatic Carcinoma
f ) Prostatic Carcinoma
g ) TesticularTeratoma
INSTRUCTION: For each of the patients below, choose the most likely underlying diagnosis from the list above. All are malignant diseases which may metastasise. Each option may be used once, more than once or not at all.
1 . A 72 year old man presents with fatigue and weight loss. There is no dysphagia nor post prandial fullness. His appetite has been poorer and bowel motions have become more frequent and loose. Abdominal examination reveals no masses. There is some tenderness in his RIF. Hb. is 9.2g/l and serum ferritin 15. Faecal Occult Blood test is positive.
The Correct answer is b.
2 . A 66 year old man presents with reduced appetite and weight loss over a three month period. He has felt nauseated with a feeling of epigastric fullness .There is no dysphagia. He has had no abdominal pain. He has noticed that his urine is dark and bowel motions are pale. On examination, he appears icteric. His abdomen reveals no masses; there is slight discomfort in the epigasrium.
The Correct answer is e.
3 . A 47 year old man relates that for the last two months he has experienced right sided abdominal and back pain. He is eating normally and has noted no weight loss. His bowels may be a little looser. He feels profoundly weak. He sweats a lot. On examination, there are no abdominal masses; there is tenderness in the right flank. He has quite marked acne vulgaris. BP 170/106. Urinalysis is negative. Hb is 14.2g/l. U & Es show hypokalaemia and hypernatraemia.
The Correct answer is a.
The symptoms of cancer of the colon differ according to the part of the colon affected and the type of tumour, but pain is common to all types. Unexplained weakness and anaemia are characteristic of right colonic carcinoma whilst a change in bowel habit feature in left colonic carcinoma. In Pancreatic carcinoma the classic symptoms are - weight loss, abdominal pain, loss of appetite, jaundice, nausea and vomiting, weakness, fatigue, diarrheoa, indigestion, back pain, clay-colored stools. Adrenocortical carcinomas are typically bulky, greater that 1.5 cm in diameter and invade locally with early spread to the liver, regional lymph nodes and the lungs. Half the tumours are physiologically active with hypercortisolism and/or excessive androgen production.
4. A 37 year old man presents thinking he may have caught Chlamydia through sexual contact with his partner. You agree to test him for infection. Which is the single most appropriate sample to send to the laboratory?
a ) A first void urine sample
b ) A midstream urine sample
c ) An early morning urine sample
d ) A semen sample
e ) A twenty four hour urine sample
Answer: A
SIGN no.42 on Management of Genital Chlamydia trachomatis infection states that the sample of choice for men or women is first void urine. The main alternative in women is an endocervical swab. A urethral swab in men is no more sensitive than first void urine and causes discomfort. The recommended test is a nucleic acid amplification test in which a ligase chain reaction or polymerase chain reaction amplifies the DNA. This test has almost 100% sensitivity, compared with 60-80% for antigen detection.
5. OPTIONS:
a ) Cardiac arrhythmia
b ) Parkinson’s disease
c ) Epilepsy
d ) Intermittent delirium
e ) Myopathy
f ) Meniere’s disease
g ) Transient ischaemic attack
INSTRUCTION: Each of the following patients has had an unwitnessed fall in the past week. Choose the single most likely cause from the above list. Each option can be used once, more than once or not at all.
1 . An 83 year old woman, on long term treatment for temporal arteritis, says she got no warning of the fall and just collapsed. She did not lose consciousness. When seen, her HR was 80/min and regular. BP 150/90 sitting and 148/88 standing. Her limbs showed poor musculature and strength -especially her thighs.
The Correct answer is e.
2 . An 80 year old man has suffered from hypertension for many years. He takes Aspirin. Perindopril and Atorvastatin. He says he felt slightly dizzy at the time of the fall. He also says that recently he has been walking much more slowly and has tripped on a number of occasions. He did not lose consciousness. On examination, his HR was 68/min. BP 120/78 sitting and 100/60 standing. His limbs showed no weakness but appeared very rigid.
The Correct answer is b.
3 . An 85 year-old woman has had hypertension for 20 years. She takes Enalapril and Simvastatin. Her husband thought she seemed confused immediately after the fall but her speech was difficult to make out. She was back to normal within an hour. On examination, HR 88/m and regular. BP160/100 sitting and 160/96 standing. Her limbs showed normal power.
The Correct answer is g.
Falls are usually multifactorial, and are caused by a combination of environmental factors and factors intrinsic to the patient. Long – term steroids can cause significant muscle wasting. Previously undiagnosed Parkinson’s Disease should be kept in line as a cause of an unexplained falls.
No comments:
Post a Comment