Spring 2004-05 Final MB Part II EMQ Paper 3

Page 01

Theme: Hand signs on examination

A. ClubbingB. Heberden’s nodesC. Hypothenar wastingD. Janeway lesionsE. KoilonychiasF. OnycholysisG. Peripheral cyanosisH. Raynauds phenomenonI. Thenar wastingJ. Thin skinK. Wrist drop

From the above list of options select the most likely physical sign you might expect to find in the following cases.

1. A 32-year-old female presents with a 6 month history of depression, weight gain and has developed diabetes. On examination she has a proximal myopathy and obvious central adiposity.

2. A 56-year-old male presents with a 6 month history of nocturnal tingling in the right hand. He works on the highways and uses vibrating tools. He has to get up some nights and shake his hand to obtain relief. He has also noticed some weakness of grip

3. A 56-year-old female presents with a four month history of weakness, fatigue and dysphagia. She finds problems swallowing and has soreness on the sides of her mouth.

4. A 42-year-old male has a flare up of plaque psoriasis

My answers:

1. J – Thin SkinThis patient has features of Cushing’s syndrome – a history of weight gain (and subsequent central adiposity), new onset diabetes, depression and proximal myopathy. Cushing’s syndrome is due to an excess of corticosteroids and has clinical features that correlate with the side effects of long term corticosteroid therapy. Thin skin is another features of excess corticosteroid and is likely to be present in this patient.

2. I – Thenar wastingMedian nerve injury can cause weakness of grip. Occupational history of use of “vibrating tools” increases the likelihood of a hand neuropathy and Carpal Tunnel Syndrome. Hypothenar wasting is less likely to be associated with weakness of grip.

3. E – Koilonychia Koilonychia is a nail disorder associated with iron deficiency anaemia. The nails lose their convexity and become flattened or concave (sometimes thought of as the opposite of clubbing). Koilonychia means “spoon nails”. Koilonychia occurs in Plummer-Vinson syndrome, also called sideropenic dysphagia, where chronic iron deficiency anaemia leads to formation of oesophageal web causing dysphagia. This patient has features of Plummer-Vinson syndrome including dysphagia with associated sore throat and has features of anaemia including angular stomatitis, chronic weakness and fatigue.

4. F - OnycholysisPsoriasis is associated with many nail changes including pitting, onycholysis, thickening and subungual hyperkeratosis.

Page 02

Theme: Liver Disease

A. Alpha-1 antitrypsin deficiencyB. Autoimmune hepatitisC. Gilbert’s diseaseD. HaemochromatosisE. Hepatitis AF. Hepatitis BG. Hepatitis CH. Portal vein thrombosisI. Primary biliary cirrhosisJ. Sclerosing cholangitisK. Wilson’s disease

From the above list of options select the most likely diagnosis for the following cases.

1. A 30-year-old woman presents with anorexia, nausea, and fatigue. Examination reveals palmar erythema and spider naevi. Liver transaminase enzymes are elevated and anti-smooth muscle antibodies are present.

2. A 52-year-old woman complains of pruritus and lethargy. On examination she has hepatosplenomegaly but no other signs of liver disease. Blood tests reveal a raised alkaline phosphatase, gamma GT and the presence of anti-mitochondrial antibodies.

3. A 13-year-old boy has right upper quadrant discomfort, nausea and mild jaundice. Examination reveals a tremor and his school performance has recently deteriorated. Viral and autoimmune serology was negative.

4. A 20-year-old man with a past medical history of ulcerative colitis presents with fatigue, weight loss, pruritus, right upper quadrant pain and intermittent jaundice.

5. A 42-year-old male presents with weakness, lethargy, impotence, and arthralgia in the hands and knees. On examination he is tanned and hepatomegaly is noted

My answers:

1. B – Autoimmune hepatitisThis patient has features of chronic hepatitis (anorexia, nausea and fatigue) and some stigmata of chronic liver disease (palmar erythema and spider naevi). The blood tests show liver dysfunction and suggest an autoimmune cause as there are anti-smooth muscle antibodies present. SMA are elevated in autoimmune disease. This is unlikely to be primary sclerosing cholangitis because of the absence of obstructive jaundice and primary biliary cirrhosis usually has elevated AMA making autoimmune hepatitis the most likely option.

2. I – Primary Biliary CirrhosisThe presence of AMA and liver disease should instantly bring to mind this diagnosis. 98% of cases of primary biliary cirrhosis (PBC) have raised AMA. The clinical presentation is consistent with this diagnosis.

3. K - Wilson’s diseaseThis young patient has features of hepatitis and CNS dysfunction. Wilson’s disease is a disorder of copper excretion where excess copper affects the liver and the CNS. We are told that this is unlikely to be autoimmune or viral by the serology result further increasing the likelihood of Wilson’s disease.

4. J – Sclerosing cholangitisThis patient has features of sclerosing cholangitis – signs of chronic liver disease with a background of intermittent jaundice – and a history of a condition associated with this disorder (Ulcerative Colitis) making sclerosing cholangitis the most likely diagnosis.

5. D - HaemochromatosisThis patient has features of multi-organ dysfunction – joint pain, impotence, muscle weakness, skin pigmentation and hepatomegaly. The multisystem presentation suggests a general problem. In this case Haemochromatosis can account for all of the symptoms. It is a disorder of iron-uptake where excess iron is deposited in the liver, heart, joints, skin, pancreas, pituitary and adrenal glands. It is more common in middle aged males like this patient because menstrual bleeding is protective in women.

Haemochromatosis = "Bronze diabetes"

Page 03

Theme: Upper Gastrointestinal Haemorrhage

A. Peptic ulcerB. Acute erosive gastritisC. Oesophageal varicesD. Mallory-Weiss tearE. Gastric leiomyomaF. Aorto-enteric fistulaG. OesophagitisH. Duodenal lymphoma

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

1. A 47 year old alcoholic presents to casualty with a profuse haematemesis. He is found on examination to be jaundiced, mildly confused with ascites and a liver flap. His serum albumin is markedly low

2. A 21 year old student is brought into casualty with severe vomiting and diarrhoea. He has just returned from a holiday in Sri Lanka and is dehydrated. He continues to vomit and then complains of severe retrosternal pain and has a haematemesis.

3. A warden in a block of flats is called to see a 62 year old with a massive haematemesis. He has a midline laparotomy scar which is more than 3 weeks old and is vomiting large quantities of fresh blood.

4. A 70 year old man is taken to theatre with a massive upper GI bleed. At laparotomy he is found to have a large mass in the gastric body which is rubbery in nature and is bleeding profusely

5. A 42 year old man who is previously fit and well presents with a sudden onset of haematemesis. He has noticed malaena stool during the day and is on no medication

1. C – Oesophageal varicesThis patient has a history of alcoholism and has signs of cirrhosis including confusion, liver flap, low serum albumin and ascites. Alcoholic cirrhosis is the most common cause of portal hypertension in the UK and oesophageal varices are a common sequelae of portal hypertension. Bleeding varices can cause profuse haematemesis and the bleeding can be difficult to control.

2. D – Mallory Weiss tearMallory Weiss tear is haematemesis due to bleeding from a tear in the oesophagus caused by vomiting. This patient has a background history of travel and severe vomiting and diarrhoea. The vomiting is likely to have caused the tear in the oesophagus and the subsequent haematemesis. The retrosternal pain is consistent with the tear. The young age of the patient makes other diagnoses less likely.

3. F – Aorto enteric fistulaThis patient has a history of recent surgery so you should be looking for a surgical complication. Aorto enteric fistula can occur following aortic aneurysm repair – the laparotomy scar is consistent with this operation. This is a bit of a stretch but this is the main surgical complication in the option list so I think it is the most likely answer.

4. E – Gastric leiomyomaThe finding of a large rubbery mass in the gastric body suggests a neoplasm of some sort. Two of the options given represent neoplasia – duodenal lymphoma and gastric leiomyoma. The description of the mass as rubbery makes the benign leiomyoma more likely. This is also more common than the extrememly rare presentation of duodenal lymphoma making it the most likely diagnosis.

5. A – Peptic UlcerThis patient was previously fit and well and has presented with haematemesis and melaena. This is most likely to be due to a peptic ulcer as the diagnosis is often made when the ulcer begins actively bleeding. The patients age fits and the lack of any signs of liver disease fit with this diagnosis.

Page 04

Theme: Treatment of Stroke

A. Percutaneous endoscopic gastronomy (PEG) feedingB. PhysiotherapyC. Observe and monitorD. NG tube feedingE. Lipid lowering agentF. Referral to psychiatristG. WarfarinH. Aspirin and dipyridamoleI. Graduated compression stockingJ. Anti-hypertensive agentK. Vascular or neuro surgery

For each case below choose the single most appropriate treatment from the above list of options. Each option may be used once, more than once or not at all.

1. A 76-year-old woman with a two week history of right sided weakness, which has more or less resolved. CT of head confirms cerebral infarction. Her pulse is irregularly irregular, but her heart sounds are normal. She is not on any medication.

2. A 76-year-old woman is found collapsed at home. On arrival at hospital, her GCS is 3. Her CT

head shows cerebral haemorrhage.

3. A 56-year-old man has been waking up nearly 3 hours of the morning and at times been tearful since his stroke 12 months ago. However, he denies depression. On examination, he is apathetic and has a dense right hemiparesis.

4. A 56-year-old man presents with a transient slurring of speech and dropping of the mouth. He is normally fit and well. A carotid ultrasound Doppler scan has confirmed 80% stenosis of the origin of the right internal carotid artery. All his other investigations have been normal.

5. A 67-year-old man has been admitted into hospital for the last 1 week with a dense left hemiparesis. He has kept nil by mouth since his admission, because of his unsafe swallow.

1. G – WarfarinThis patient is at high risk of further stroke as she is in AF and is over 70. Warfarin would be the longterm anticoagulant of choice for someone in AF but should be thoroughly discussed with the patient before therapy commences.

2. K – Vascular or neuro surgeryThis patient requires evacuation of the cerebral haemorrhage by a surgeon.

3. F – Referral to a psychiatristDepression is very common following a stroke. This patient is found to be apathetic and reportness sleep disturbance and tearfulness - these are signs of depression and indications for referral to a psychiatrist despite the patient denying any problem. This patient also requires rehabilitation for his stroke and should be receiving physiotherapy input for his hemiparesis.

4. C – Observe and monitorThere's not much a surgeon can do since the bleed is within the substance of the brain.

5. D – NG Tube FeedingThis patient has difficulty swallowing safely but there is no indication given that he has any other problems with the upper GI tract. NG tube feeding should be the supportive treatment in choice while PEG feeding is reserved for patients whose disease prevents NG tube feeding.

Page 05

Theme: Diagnosis of joint pain

A. Ankylosing spondylitis B. Erythema nodosumC. GoutD. HaemochromatosisE. HyperparathyroidismF. Joint sepsisG. Medial cartilage tearH. OsteoarthritisI. Psoriatic arthropathyJ. Pyrophosphate arthropathyK. Reactive arthritisL. Rheumatoid arthritis

1. A 30 year old woman presents with a 10 year history of back pain, worse in the morning and one episode of iritis

2. A 22 year old male soldier presents with a two week history of a swollen right knee, conjunctivitis and arthritis

3. A 70 year old fit farmer presents with pain on weight bearing and restricted movements of the right hip

4. A 73 yearr old woman with rheumatoid arthritis on immuno-suppressive drugs presents with systemic malaise and fever and has redness, heat and swelling of the wrist

5. An elderly woman started furosemide two weeks ago and now presents with a red, hot, swollen metatarsal phalangeal joint

My answers

1. A – Ankylosing spondylitisAnkylosing spondylitis typically affects young men but women are affected and tend to present a little later – this patient is female and 30. The symptoms of chronic back pain that is worse in the morning are typical of ankylosing spondylitis. Acute anterior uveitis (iritis) occurs in 1/3 of ankylosing spondylysis patients. Ankylosing spondylitis is usually HLA-B27 positive.

2. K – Reactive ArthritisThis young, male patient has a history of monoarthropathy and conjunctivitis. These are two of the three features of Reiter’s syndrome; a triad of conjunctivitis, urethritis and reactive arthritis. The presence of mono-arthritis in a young male should bring to mind the possibility of reactive arthritis and the concurrent conjunctivitis confirms this as the most likely diagnosis.

3. H - OsteoarthritisThis older patient has a history of an active occupation. Given his age he is more likely to have developed osteoarthritis. The large joints are more commonly affected. The symptoms of restricted movement and pain on weight bearing are quite general and do not point at any specific alternative.

4. F – Septic ArthritisThe presence of a new mono-arthropathy with associated systemic symptoms and an exaggerated inflammatory response should suggest septic arthritis in any patient. This patient is immuno-suppressed and therefore more likely to contract infections. Her rheumatoid arthritis would flare up in a familiar and predictable way – typically affecting the smaller joints of the hand. This is presented as a supervening mono-arthropathy and septic arthritis is therefore more likely than a simple flare up.

5. C – GoutBeginning diuretics, like furosemide, can often precipitate an attack of gout. The small joint mono-arthropathy described is consistent with gout – metatarsophalyngeal is characteristic.

Page 06

Theme: Investigation using serum antibodies

A. Anti-centromere antibodiesB. Anti-mitochondrial antibodiesC. Anti-nuclear factor antibodiesD. Anti-phospholipid antibodiesE. Anti-smooth muscle antibodiesF. c anti-neutrophil cytoplasmic antibodies (cANCA)

G. Double stranded DNA antibodiesH. Extractable nuclear antigen antibodiesI. P anti-neutrophil cytoplasmic antibodies (pANCA)J. Rheumatoid factor antibodiesK. scl-70 antibodies

For each presentation choose the single most discriminating investigation from the above list of options. Each option may be used once, more than once or not at all.

1. A 45-year-old woman is found incidentally to have a raised alkaline phosphatase through routine blood tests done during a medical examination. Examination reveals mild generalised pigmentation.

2. A 45-year-old woman presents with a thrombotic stroke with right sided weakness, having had 3 previous miscarriages. She has a mild thrombocytopenia

3. A 50-year-old woman presents with a 6 month history of difficulty swallowing and painful hands when exposed to the cold. Examination reveals telangiectasia in her face and shiny and tight skin over her fingers with atrophy of her finger pulps.

4. A 38-year-old man complains of morning pain and joint stiffness, mainly affecting his hands for the last 3 months. X-ray of his hands shows soft tissue swelling and bony erosions.

5. A 35-year-old woman presents with severe chest pain, relieved when sitting forward. She also complains of arthralgia, myalgia and malaise. Examination reveals facial erythema and pericardial rub.

1. B – Anti-mitochondrial antibodyIncidental finding of a raised Alk Phos is a common method of presentation of both Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis. Both can cause pigmentation as they cause jaundice. PBC is strongly associated (95%) with elevated levels of anti-mitochondrial antibodies (AMA). This would be the most discriminating test in this case as PSC is not as strongly associated with any antibody.

2. D – Anti-phospholipid antibodiesThis patient has a mild thrombocytopenia and a significant history of thrombotic events (recurrent miscarriage and a recent stroke). She is likely to have antiphospholipid syndrome and this can be confirmed by the presence of anti-phospholipid antibodies. An acronym can be used to remember the features of antiphospholipid syndrome: CLOT – Coagulation defect, Livedo reticularis, Obstetric recurrent miscarriage and Thrombocytopenia.

3. A - Anti-centromere antibodiesThis patient has Raynaud’s phenomenom, sclerodactyly, dysphagia (oEsophageal dymotility), and telangiectasia. These are 4 of the 5 features of CREST and she is likely to have limited systemic sclerosis. Anti-centromere antibodies are found in 70-80% of patients with this condition so this would be the first line autoantibody assay. scl-70 antibodies are positive in 40% of patients with the diffuse form of the disease so would not be as discriminating in this case of probable limited systemic sclerosis.

4. J – Rheumatoid factor antibodiesThis patients has chronic morning joint pain and stiffness concentrated on the hands – he is likely to have rheumatoid arthritis. Rheumatoid factor is positive in 70% of patients with RA and is the most discriminating test in this condition.

5. C – Anti-nuclear antibodies Alternatively G. dsDNAThis patient has pericarditis (severe positional chest pain and a pericardial rub) and associate

arthralgia, myalgia, malaise and facial arythema. She is likely to have systemic lupus erythematous (SLE). 95% of patients with SLE are ANA positive. Anti-dsDNA antibodies are present in only 60% of patients but this is a much more specific test. As ANA is more sensitive I would select this option. Both are part of the diagnostic criteria for SLE.

Page 07

Theme: Diagnosis of back pain

A. OsteoarthritisB. PancreatitisC. OsteoporosisD. Acute disc prolapseE. Dissecting aneurysmF. Ankylosing spondylitisG. Spinal stenosisH. PsychogenicI. OsteomalaciaJ. MetastasesK. Paget’s disease

For each case below choose the single most likely cause from the above list of options. Each option may be used once, more than once or not at all.

1. A 35 year old man with chronic renal failure complains of proximal muscle weakness and middle back pain. X-ray of his back revealed vertebral bodies to be reduced in density and biconcave (cod-fish vertebrae).

2. A 55 year old man presents with a sudden onset of severe and continuous lower back whilst lifting some heavy boxes. Examination revealed loss of lumbar lordosis with a compensatory scoliosis.

3. A 50 year old woman develops a sudden onset of tearing chest and back pain. There is evidence of radio-femoral delay.

4. A 70 year old man has severe back pain for the last 6 months. He has late-onset asthma and has been on long term steroids. Examination revealed kyphosis.

5. A 75 year old woman presents with weight loss and middle back pain. There is collapse of T12 vertebra.

Answers1. I - Osteomalacia“Cod fish” or biconcave vertebrae occur in osteopenia. Osteopenia is a desriptive term that means low bone density but does not imply causality. The presence of chronic renal failure suggests that osteomalacia is the cause. Osteomalacia means a low mineral content in the bone. It can occur in chronic renal failure due to 1,25-dihydroxcholecalciferol deficiency.

2. D – Acute Disc ProlapseThe sudden onset and association with exertion suggest a mechanical problem. The examination findings are consistent with a disc prolapse. The patients age actually goes against this diagnosis – disc prolapse is most common in those under 50.

3. E – Dissecting aneurysmRadio-femoral delay is a sign of a dissecting aortic aneurysm. The sudden onset and tearing nature of the pain suggest an aneurysm. The chest pain radiating to the back also suggests an

aneurysm.

4. C – OsteoporosisLong term steroid use can cause osteoporosis. Kyphosis is a common finding in patients with osteoporosis. This patient is 70 and is in the age group commonly affected by osteoporosis.

5. J - MetastasisThis patient has back pain combined with a systemic symptom – weight loss. The collapse of a vertebra suggests malignancy and in combination with the weight loss this is the most likely diagnosis. The patients age (75) makes a malignancy more likely.

Page 08

Theme: Diagnosis of peripheral neurological lesions

A. Median nerve lesionB. Ulnar nerve lesionC. Brachial plexus lesionD. Cord compressionE. Cauda equina lesionF. Autonomic neuopathyG. Radial nerve lesionH. Peripheral neuropathyI. Multiple sclerosis (demyelination)J. Anterior horn cell disease (motor neurone disease)K. Sciatic nerve lesion

For each case below choose the single most likely cause from the above list of options. Each option may be used once, more than once or not at all.

1. A 55 year old man complains of left shoulder pain and weight loss. There is evidence of miosis and partial ptosis of his left eye.

2. A 38 year old pregnant woman complains of tingling sensation in her hands, worse at night. Her Tinel’s and Phalen’s signs were positive

3. A 72 year old woman presents with bilateral foot drop and spastic weakness with muscle fasciculation of her legs. Recently, she has been prone to having chest infections. Her tongue was wasted and fasciculating.

4. A 70 year old diabetic man complains of impotence and intermittent vomiting, with abdominal distension after eating. He also has postural hypotension.

5. A 75 year old man complains of bilateral lower limb weakness, numbness and urinary incontinence. His knee and ankle reflexes are absent. There is loss of sensation in the sacral dermatomes.

My answers:

1. – Apical Lung CancerMiosis and ptosis are features of Horner’s syndrome. Combining this finding with the shoulder pain suggests a polyneuropathy. If it is MS it is usually a younger women

2. A – Median Nerve LesionThis woman has a median nerve lesion and is likely to have carpal tunnel syndrome. The sensory symptoms being worse at night is characteristic. Tinel’s and Phalen’s signs are non-specific signs

that are positive in carpal tunnel syndrome. Tinel’s sign is tingling in the hand after tapping on the wrist over the median nerve. Phalen’s sign is reproduction of the symptoms after holding the wrist in the flexed position for a minute.

3. J – Anterior Horn Cell Disease (Motor Neurone Disease)Weakness and spasticity suggest and upper motor neurone lesion. Fasciculation suggest a lower motor neurone lesion so there is a mixed picture. Along with the widespread and progressive nature of the nerve involvement this suggests Motor Neurone Disease. There is no sensory loss which is consistent with MND and helps to distinguish it from multiple sclerosis.

4. F – Autonomic NeuropathyPostural hypotension and erecticle dysfunction are both features of autonomic neuropathy. The association of distension and vomiting suggests that there is damage to the innervation of the bowels also.

5. E – Cauda equina syndrome

Page 09

Theme: Diagnosis of Proximal Muscle Weakness

A. Cushing’s syndromeB. Diabetic amyotrophyC. Non-metastatic manifestation of malignancyD. PolymyositisE. HypocalcaemiaF. ThyrotoxicosisG. Duchenne Muscular Dystrophy (DMD)H. HypokalaemiaI. HypothyroidismJ. Polymyalgia rheumatica

For each case below choose the single most likely cause from the above list of options. Each option may be used once, more than once, or not at all.

1. A 47 year old woman presents with symmetrical proximal muscle weakness and wasting. Her muscles are tender, with reduced tendon reflexes. Serum creatinine phosphokinase (CPK) is elevated.

2. A 45 year old woman with long standing asthma complains of obesity and proximal muscle weakness. She requires a maintenance steroid dose of at least 15mg prednisolone per day.

3. A 70 year old man complains of 2 months history of painful thighs and difficulty getting up from a chair. Examination revealed wasting of the quadriceps with absent knee reflexes. His glycosylated haemoglobin is elevated at 9.

4. A 7 year old boy has hypertrophy of his calves and has a waddling gait. He also displays the Gower sign, due to weakness of his spine and knees.

5. A 56 year old man with recently diagnosed chronic renal failure, complains of paraesthesia, cramps, proximal muscle weakness and tetany. Both Chvostek’s and Trousseau’s signs were elicited.

1. D - PolymyositisThis patient has symmetrical muscle weakness suggesting a systemic disease process. There is tenderness (suggesting inflammation) and reduced reflexes suggesting a peripheral problem

(rather than UMN lesions which increase reflexes). The raised CPK is the most important factor here – it is a muscle enzyme and its increase represents inflammation of the muscles. Polymyositis causes muscle inflammation and presents with symmetrical proximal muscle weakness and wasting, tenderness and elevated muscle enzymes so it is the most likely diagnosis.

2. A – Cushing’s syndromeThis patient has a clear history of longstanding steroid use because of her asthma. She is suffering from weight gain causing obesity and proximal muscle weakness which are features of Cushing’s syndrome (due to an excess of steroids).

3. B – Diabetic amyotrophyAmyotrophy is a progressive loss of muscle bulk with associated muscle weakness. It is a feature of chronic neuropathy and may be the most prominent neurological symptom of diabetes mellitus. This patient has an elevated glycosylated haemoglobin suggesting long term hyperglycaemia. The absence of reflexes suggests a lower motor neurone lesion which is consistent with diabetic neuropathy.

4. G - Duchenne Muscular Dystrophy (DMD)The very young age of this patient should call to mind the possibility of a genetic condition. DMD is X-linked recessive and only affects boys. Muscle hypertrophy due to fat deposition is a common feature. Waddling gait is due to muscle weakness creating instability. Gower sign is the classical finding of having to use the hands and arms to ‘‘climb up” the legs in order to reach a standing posture.

5. E - HypocalcaemiaParesthesiae, cramps, proximal muscle weakness and tetany are all features of hypercalcaemia. Chvostek’s sign is a specific sign of hypercalcaemia where tapping over the facial nerve produces facial twitching. Likewise Trousseau’s sign is specific to hypercalcaemia and is spasmodic flexion of the wrist when the brachial artery is occluded by the blood pressure cuff. Hypercalcaemia is common in chronic renal failure.

Page 10

Theme: Diagnosis of Visual Defect

A. Bitemporal hemianopiaB. Left homonymous hemianopiaC. Tunnel visionD. Increased size of blind spotE. Right homonymous hemianopiaF. Cortical blindnessG. HysteriaH. Central scotomaI. Amaurosis fugaxJ. Uniocular visual lossK. Night glare

For each case below choose the single most likely cause from the above list of options. Each option may be used once, more than once, or not at all.

1. A 27 year old woman complains of visual problems and weakness of both legs. She had weakness in her left arm 3 months ago, which resolved. Fundoscopy reveals optic atrophy.

2. A 54 year old woman complains of coarsening of her facial features, sweats and headaches. She also has a visual deficit.

3. A 75 year old woman presents with deterioration of her eyesight. She has been on various eye drops for a number of years. Her pupils are small and not reactive to light

4. A 65 year old woman is blind on testing but denies that there is a problem with her eye sight.

5. A 70 year old man presents with a sudden onset of mild right sided weakness, and has noticed that he has been bumping into things.

1. H – Central scotomaThis relatively young patient has a history of remitting weakness in her arm and is now presenting with optic nerve atrophy and weakness in the legs. This suggests a polyneuropathy. Multiple sclerosis is the most likely cause. The demyelination of the optic nerve causes a central scotoma. Multiple sclerosis affects women more commonly than men and has a mean age of presentation of 30 fitting with the sex and age of the patient in the stem.

2. A – Bitemporal hemianopiaThis patient has features of a pituitary tumour – visual defect, coarsening of facial features (due to acromegaly indicating that the tumour is growth hormone secreting), sweats and headaches (from local pressure effects). Pituitary tumours compress the optic chiasm and cause a bitemporal superior quadrantonopia initially progressing to the classic bitemporal hemianopia.

3. C – Tunnel visionI think that 3 is glaucoma - and that this gives tunnel vision? The small pupils are from miotics (pilocarpine)

4. F – Cortical blindnessThere is a rare syndrome called Anton’s blindness that involves complete loss of vision due to cortical damage but denial of any blindness due to a lesion in the occipital lobe. The findings in this stem are consistent with this syndrome but this is a bit obscure for my taste.

5 E- Right homonymous hemianopia

After the optic chiasm, the left field of vision is supplied by the right side of the brain, so a left cortical defect will cause right visual problems.

Page 11

Theme: Diagnosis of Pleural Effusion

A. Cardiac failureB. ChylothoraxC. CirrhosisD. Dressler’s syndromeE. Lung carcinomaF. MesotheliomaG. Nephrotic syndromeH. Pulmonary embolismI. Rheumatoid arthritisJ. SLEK. Yellow nail syndrome

For each presentation choose the single most likely cause from the above list of options. Each option may be used once, more than once or not at all.

1. A 65-year-old man presents with worsening breathlessness over the last 6 months. Chest x-

rays show small bilateral pleural effusions and cardiomegaly.

2. A 65-year-old retired electrician is found to have a left pleural effusion. There is also radiological evidence of irregular pleural thickening

3. A 30-year-old woman is found incidentally to have a small right pleural effusion. She has evidence of a red papular facial rash with scarring and follicular plugging.

4. A 57-year-old man is readmitted 4 weeks after a myocardial infarction with a febrile illness. There is a pericardial rub and radiological evidence of a small left pleural effusion

5. A 50-year-old man presents with a right pleural effusion after oesophagectomy for carcinoma. Pleural aspiration yields a milky fluid.

1. A – Cardiac FailureThis patient is older than the other examples, has a chronic progressive presentation of breathlessness and his chest X-ray shows bilateral effusion and cardiomegaly. Bilateral effusion means that the cause is more likely to be general than local to the pleura. Cardiomegaly suggests cardiac failure which fits well with the presentation.

2. F – MesotheliomaThis patient’s occupational history should call to mind the possibility of asbestos exposure as it was used extensively as electrical insulation before its harmful effects were understood. Abestos exposure causes pleural plaques, asbestosis and mesothelioma as well as increasing the risk of bronchial carcinoma. The radiological finding of irregular pleural thickening makes mesothelioma the most likely diagnosis because the lesion has been identified as pleural and pleural plaques appear smooth while malignancy like mesothelioma is irregular. At 65 the patient is old enough to have mesothelioma which typically develops many years after the initial exposure.

3. J – SLESLE (Systemic Lupus Erythematous) is a connective tissue disorder that often presents with a malar facial rash. It is also a cause of pleural effusion.

4. D – Dressler’s SyndromeDressler’s syndrome is a form of pericarditis that occurs in the setting of injury to the heart or the pericardium. It is also know as postmyocardial infarction syndrome and postcardiotomy pericarditis. The syndrome consists of a low grade fever, chest pain, a pericardial friction rub and sometimes a pleural effusion. It usually presents a few weeks or months after the original injury and settles quickly. This patient has presented in the right time frame (4 weeks post MI) with several of the characteristic symptoms including pyrexia, pericardial rub and the effusion.

5. B – ChylothoraxChylothorax is the presence of lymphatic fluid (chyle) in the pleural space. Usually secondary to leakage from the thoracic duct. This can occur secondary to traumatic damage to the duct and can be a complication of mediastinal surgery. The history of oesophagectomy suggests a surgical cause of the effusion and the milky nature of the fluid increases the likelihood of chylothorax.