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SBA answers
disease (Hashimoto thyroiditis) would be the most
common cause in this middle-aged woman with
coexisting autoimmune disease. There is nothing
in the vignette to suggest she has been treated
previously for hyperthyroidism. Iodine deficiency
is now very rare in the United Kingdom. Graves
disease is associated with hyperthyroidism.
Secondary hypothyroidism from a pituitary disease
(e.g., a pituitary adenoma) or a hypothalamic
disorder is extremely rare.
8. B. Autoimmune destruction is most common in the
developed world; worldwide, infection, especially
TB, is more common. Diagnosis is made with
the short Synacthen test. Rehydration, correction
of electrolyte abnormalities and replacement of
cortisol with hydrocortisone are most important
in a crisis. In the long term, most patients also
require fludrocortisone. Hyperpigmentation is seen
in Addison disease, but there is an association with
vitiligo.
9. A. Sinus tachycardia is also common. Menorrhagia
occurs in hypothyroidism; thyrotoxicosis causes
amenorrhoea. Pretibial myxoedema, proptosis
and clubbing (thyroid acropachy) are all specific to
Graves disease.
10. D. ADH (also called ‘arginine vasopressin’) is
synthesized predominantly in the hypothalamus and
is released by the posterior pituitary. Oxytocin is the
other hormone secreted by the posterior pituitary.
The main hormones secreted by the anterior pituitary
are TSH, ACTH, GH, LH, FSH and prolactin.
Chapter33 Musculoskeletal system
1. D. Psoriatic arthritis is the most likely cause given
the patient’s age and pattern of involvement.
DIP joint involvement and dactylitis together with
nail disease is characteristic of psoriatic arthritis.
She may also suffer from spondyloarthropathy
(limited spinal movements) and inflammatory bowel
disease (bloody diarrhoea), which are associated
with psoriatic arthritis and should be further
investigated.
2. Methotrexate is terratogenic and should not be used
in women planning pregnancy.
3. A. Primary or idiopathic OA affects the DIP and
carpometacarpal joints in the hands, MTP joints
in the feet, the knee, hip, shoulder and spine. If
other joints are affected, then this is more likely due
to a secondary cause (e.g., congenital disorders,
trauma, infection or metabolic, endocrine or crystal
deposition diseases).
4. B. This is a classic presentation if prolonged IM gold
therapy is used. This skin discolouration is known as
‘chrysiasis’ and is otherwise usually asymptomatic
apart from the obvious cosmetic appearances. Often
if patients are achieving good disease control with
the IM gold therapy they are willing to accept the
skin discolouration.
5. B. Granulomatosis with polyangiitis is a cytoplasmic
ANCA-positive, small-vessel vasculitis which
can affect any organ. It is fatal if left untreated,
and typically presents with respiratory signs and
symptoms, including sinusitis, rhinitis, epistaxis and
haemoptysis. It is characterized by the formation
of necrotizing granulomata (in this case most likely
in the lungs). Glomerulonephritis is also common.
Treatment is with high-dose steroids followed by
immunosuppression in the longer term
(e.g., cyclophosphamide or mycophenolate).
PMR usually affects older patients and causes pain
and stiffness in the shoulder and pelvic girdles.
Kawasaki disease is a systemic vasculitis presenting
usually in young children.
Chapter35 Skin disease
1. B. Systemic lupus erythematosus is more common
in females. Its initial presentation often involves
a butterfly rash on the nose and cheeks. It can
be precipitated by sunlight and is associated
with vasculitis that can cause pericarditis and
glomerulonephritis. The other conditions do not
typically cause a butterfly rash on the face.
2. D. This patient has many features of this
inflammatory myopathy. Cutaneous involvement with
raised creatine kinase levels differentiates it from
polymyositis. Muscle biopsy reveals inflammation
within the muscle. Some patients will have an
underlying malignancy so it is important that this is
screened for.
3. B. The condition that would most likely cause
the features described is excess cortisol seen in
Cushing syndrome. Peripheral muscle weakness,
truncal obesity and various skin manifestations
are characteristic. Reiter syndrome usually follows
infection, and granulomatosis with polyangiitis would
present with respiratory symptoms.
4. D. Lyme disease is characterized by erythema
migrans, described here to have developed on the
patient’s legs. Lyme disease is caused by Borrelia
burgdorferi, and can also lead to arthralgia
and cardiac abnormalities. Treatment is with
antibiotics.
5. A. The most likely diagnosis is Henoch-Schönlein
purpura. This is common in young males. It is
type of vasculitis that typically follows viral upper
respiratory tract infection. It is characterized by a
purpuric rash on the back of the legs and buttock.
In most cases, Henoch-Schönlein purpura is selflimiting, with full recovery. It is rare in children that
renal failure will develop.
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Chapter36 Haematological disorders
1. E. Even though both Hb level and reticulocyte
count can be useful in determining the baseline for
a sickle cell anaemia patient, there is no definitive
investigation that will confirm a vasoocclusive crisis.
This is a clinical decision based on the history
and examination findings, and even though Hb
electrophoresis, sickle cell solubility and blood film
can confirm the diagnosis, these should not delay
prompt management.
2. B. ALL is present in both children and adults. The
highest incidence is between the age of 2years and
the age of 5years. ALL is the most common cancer
of childhood. ALL is less common in adults but
shows a gradual increase in incidence after the age
of 50years.
3. E. This man could have chronic liver disease.
Acanthocytes are spiked red blood cells (RBCs) that
are commonly found in chronic liver problems. They
are also present in α-thalassaemia trait. Pencil cells
occur in iron-deficiency anaemia or thalassaemia
traits. Schistocytes are fragmented RBCs that
become damaged when passing through vessels
in cases of intravascular haemolysis. Basophilic
stippling is seen in disorders of erythropoiesis,
and bite cells are seen in oxidative haemolysis and
glucose-6-phosphate dehydrogenase deficiency.
4. A. β-Thalassaemia is an inherited disease of
defective haemoglobin (Hb synthesis. In the case
of β-thalassaemia there is malproduction of the β
chain of Hb that results in abnormal haemopoiesis
and microcytic hypochromic anaemia. This condition
is common in people with Mediterranean origin.
There is an excess of HbA2 and more than 3.2%
is diagnostic of the disease. In anaemia of chronic
disease and iron-deficiency anaemia, one would
expect ferritin level to be low.
5. C. Haemophilia B is the most likely diagnosis. This
is a milder than haemophilia A but with a similar
presentation and is due to factor IX deficiency. It is
an autosomal recessive condition often picked up
following exacerbated bleeding after minor surgery
or trauma. Von Willebrand disease (vWD) results in
prolonged APTT but also prolonged bleeding time.
Liver disease is uncommon in 20-year-old healthy
individuals and would also lead to prolonged PT.
APTT is not prolonged in thrombocytopenia.
Chapter37 Infectious diseases
1. B. By definition, MRSA is resistant to certain
antibiotics. Therefore, NHS hospitals set
guidelines suggesting the recommended choice of
treatment. From the list above, vancomycin is the
recommended treatment, showing the highest rates
of success when compared with the development of
resistance.
2. B. The description suggests that the patient has
sepsis. National guidelines recommend following
the sepsis protocol. This includes measuring lactate
levels, obtaining blood cultures, measuring urine
output and administering oxygen, intravenous
antibiotics and intravenous fluids.
3. B. This man presents with HIV-associated
disease. Weight loss and night sweats together
with mediastinal and retroperitoneal masses are
characteristic of late TB, which is very common in
HIV-positive patients.
4. B. Antimalarial medication can cause a variety of
side effects. There are guidelines in place suggesting
appropriate use. From the list above, mefloquine
is known to be associated with episodes of
depression and psychosis, and therefore its use is
not recommended in cases of past mental health
problems.
5. B. Mycobacterium avium is a common pathogen
causing infection in immunocompromised patients.
It can cause respiratory symptoms, including a
persistent cough, fever and malaise. It can be
particularly severe in later stages of AIDS.
Chapter38 Drug overdose and abuse
1. A. Salicylate (aspirin) stimulates the respiratory
centre, resulting in hyperventilation and respiratory
alkalosis. There is compensatory renal excretion of
bicarbonate, sodium, potassium and water. This
leads to dehydration and metabolic acidosis with
electrolyte disturbance. The acidosis can increase
absorption of aspirin into the central nervous
system, resulting in reduced consciousness and
seizures. Tinnitus is a distinctive feature of salicylate
overdose. Benzodiazepine and opiate overdoses
are associated with respiratory depression. A
metabolic acidosis is also a feature of tricyclic
antidepressant overdose, but this is not associated
with tinnitus.
2. C. This is a mixed unknown overdose. In these
cases, always assume paracetamol has been taken
and treat the patient for paracetamol overdose.
Given it is 8 hours after ingestion, N-acetylcysteine
infusion should be started immediately. This can
always be stopped when the serum paracetamol
level is known. It is 8 hours after ingestion so gastric
lavage will not be effective. Paradoxically, absorption
of certain drugs will increase following administration
of activated charcoal so this should be avoided. It is
essential to monitor the patient for cardiac irritability.
Alkalinization of the urine is indicated for significant
aspirin overdoses, but should not be commenced
without the salicylate level being known.
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SBA answers
3. D. This woman has features of tricyclic overdose,
with the anticholinergic effects of dilated pupils, dry
mouth and tachycardia. This is in keeping with a
severe overdose as there is evidence of significant
QT prolongation and a severe metabolic acidosis.
Treatment should be directed at correcting
hypoxia, correcting electrolyte imbalance and
giving sodium bicarbonate to prevent arrhythmias.
She needs to be attached to a cardiac monitor.
Naloxone is the treatment for opiate toxicity;
features would include pinpoint pupils and
respiratory depression. Flumazenil is used for
known benzodiazepine overdose, and lowers
seizure threshold, so should never be given in the
context of a tricyclic overdose. N-Acetylcysteine
is the treatment for paracetamol overdose.
Digibind (A digoxin antidote containing digoxin
specific antibody Fab fragments) would be used
for significant digoxin overdose. Digoxin overdose
classically causes altered coloured vision and is
associated with a shortening of the QT interval.
4. B. This man has classical features of delirium
tremens, which classically occurs 2–3days
after cessation of alcohol intake. It is a medical
emergency, and can result in seizures. He requires
reorientation, a calm environment and treatment
with benzodiazepines. Alcohol toxicity is less likely
given that he is an inpatient and would be unlikely to
be consuming alcohol. He is at risk of developing a
Wernicke encephalopathy, but the vignette does not
describe the features of this, confusion, ataxia and
ophthalmoplegia. To prevent this he needs thiamine
treatment, which should be given intravenously, in
the form of Pabrinex (an intravenous high potency
vitamin B and C infusion). Korsakoff psychosis
is irreversible and is a late neuropsychiatric
manifestation of untreated Wernicke encephalopathy
with features of memory loss and confabulation.
There is considerable overlap between the two
conditions, and the term ‘Wernicke–Korsakoff
syndrome’ is often used. Sepsis can result in
impaired cognition and rigors which may mimic
tremors but not classically with scary visual
hallucinations.
5. C. The CIWA scale is a validated 10-item
assessment tool that can be used to quantify
the severity of the alcohol withdrawal syndrome
and to monitor and medicate patients throughout
withdrawal. The CAGE questionnaire and AUDIT-C
are screening tools to identify individuals with alcohol
dependence and alcohol misuse, respectively.
NEWS is used to identify the haemodynamically
deteriorating patient. MMSE is a 30-point scoring
system to screen patients for cognitive impairment.
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EMQ answers
Chapter28 Respiratory system
Signs on chest examination
1. E Stridor is an inspiratory noise resulting from
tracheal compression. A thyroid goitre may
displace the trachea but as it is in the midline
this may be either to the left or to the right.
2. C The trachea is pushed away by the increasing
pressure in the right hemithorax.
3. D Scarred fibrotic tissue pulls the trachea towards
itself.
4. B Airflow obstruction during expiration causes a
polyphonic expiratory wheeze.
5. J The fluid causes a stony dull percussion note and
reduced air entry. Expansion may also be reduced.
Haemoptysis
1. H In pneumonia, red cells released into the alveoli
as part of consolidation may degenerate into
browny haemosiderin pigment and be cleared
by coughing as rusty sputum.
2. F Hereditary haemorrhagic telangiectasia (Osler–
Weber–Rendu syndrome) is dominantly inherited
and associated with arteriovenous malformations
in the mucosa of the mouth, nose and
gastrointestinal tract, and in the lungs and brain.
3. B All causes of bronchiectasis can produce brisk
bleeding from dilated blood vessels in the walls
of inflamed dilated bronchi.
4. G In pulmonary oedema the fluid may be just
frothy and clear, but it may be blood stained
when red cells are also released into the alveoli.
5. E Goodpasture syndrome is associated with
antiglomerular basement membrane antibody,
which cross-reacts with basement membrane in
the lung.
Shortness of breath
1. I This patient is an ex-smoker who presented
with a cough of 4 weeks duration and
associated possible weight loss. Lung cancer
should be excluded.
2. H Cystic fibrosis is a multisystem autosomal
recessive disorder. Over 95% of males with the
disease are infertile.
3. D Interstitial lung disease presents with
progressively worsening shortness of breath.
This patient has a history of working with birds
which would predispose him to developing
hypersensitivity pneumonitis (Bird fancier’s lung)
linked to exposure to avian proteins.
4. A The patient presents with cough productive of
yellow sputum which would make pneumonia
the most likely diagnosis.
5. B The patient spent a significant amount of
time immobilised on the intensive care unit.
Additionally, history of extensive abdominal
surgery would also predispose her to a procoagulopathic state. Pulmonary embolism
should be excluded in this case.
Chapter29 Gastrointestinal and
hepatobiliary systems
Abdominal swelling
1. F This is a common place to put a transplanted
kidney. His Cushing syndrome can be explained
by steroid therapy to prevent organ rejection.
2. J Elderly men may have bladder outflow
obstruction caused by enlarged prostate
glands. These may cause urinary retention with
overflow incontinence (e.g., postoperatively).
3. D She has polycystic kidneys. These are
associated with an increased risk of
subarachnoid haemorrhage.
4. E Divarification of the recti is accentuated by
sitting up.
5. B She has ascites caused by decompensated
alcoholic liver disease. The decompensation
causes encephalopathy, and may be
precipitated by an alcohol binge.
Diarrhoea
1. H Left iliac fossa pain and bloody diarrhoea is
typical of diverticulitis.
2. C An elderly woman with a change in bowel habit
and tiredness suggesting anaemia needs to be
investigated for a possible malignancy.
3. F The absence of nocturnal symptoms points
to a nonorganic cause of the patient's
symptoms.
4. J In patients with alcoholism a common cause
of hospitalization is acute pancreatitis—with
repeated attacks and continued alcohol abuse
the pancreas does not secrete sufficient
enzymes, and malabsorption ensues.
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EMQ answers
5. E Noticeable sweating and palpitations are
suggestive of excessive thyroxine levels.
Dysphagia
1. F is a condition of mostly unknown cause
characterized by a lack of relaxation in the lower
oesophageal sphincter due to degeneration of
the myenteric plexus. Dysphagia, retrosternal
cramps, regurgitation and weight loss are
characteristic.
2. A Most patients with systemic sclerosis have
oesophageal involvement.
3. D This history suggests an obstruction in the
oesophagus. Progressive worsening in
dysphagia (from solids to fluids) suggests a
growing mass lesion.
4. J Obesity is a risk factor for GORD, and the nighttime bouts of coughing are due to aspiration of
gastric fluid.
5. C Plummer–Vinson syndrome is a narrowing
in the upper oesophagus associated with
iron-deficiency anaemia, glossitis and angular
stomatitis.
Hepatobiliary disease
1. E Iron deposition affects the joints, heart, liver,
pancreas and skin, and causes hypogonadism
because of pituitary deposition.
2. F Associated with autoimmune conditions such
as Addison disease, Raynaud syndrome,
thyroid disease and systemic sclerosis.
The lack of pain and lack of evidence of
obstruction on ultrasonography make cancer
less likely.
3. C Not simple biliary colic because of features of
peritonism and a raised WCC.
4. B A rare inherited disorder with copper
accumulation particularly in the liver and basal
ganglia.
5. H One of the causes of this is chronic
pancreatitis.
Jaundice
1. D Carcinoma of the pancreas often presents with
pain, which often radiates to the back.
2. E Ascending cholangitis is usually associated with
ulcerative colitis, and causes jaundice, fever,
rigors and sepsis.
3. G Gallstones cause acute cholecystitis; the
gallbladder is not usually palpable because of
the recurrent inflammation.
4. B The jaundice of acute viral hepatitis is often
preceded by less specific symptoms of fever,
malaise and muscle and joint pains.
5. I Leptospirosis (Weil disease) is caused by
spirochaetes. An acute viral illness is followed by
jaundice, bleeding and abdominal pain in around
10% of cases.
Investigations in gastrointestinal disease
1. A Steatorrhea occurs as a result of fat
malabsorption. Hyposplenism is a known
occurrence in patients with coeliac disease. In
a young person anti-tissue transglutaminase,
antibodies should be measured to further
investigate this malabsorption.
2. D This test is used to diagnose carcinoid
syndrome. Dry flushing (without sweating) and
diarrhoea are symptoms common in carcinoid
syndrome, which together with the presence of
a mass could suggest this condition.
3. C The test for antimitochondrial antibody is
positive in primary biliary cirrhosis (PBC). In
a woman in this age group presenting with
pruritus and obstructive jaundice, PBC should
be suspected.
4. G Acute abdominal pain radiating to the back is a
classic presentation of acute pancreatitis. In this
case amylase level should always be measured
to confirm the diagnosis.
5. H These are the signs and symptoms of
haemochromatosis. It results from excessive
iron depositing in different organs. Raised
serum ferritin level will point towards the
diagnosis.
Gastrointestinal bleeding
1. E Although the patient is known to have
haemorrhoids, rectal bleeding together with
unintentional weight loss should immediately
warrant investigations to exclude bowel cancer.
2. B Mallory–Weiss tear occurs when the mucosa
at the gastroesophageal junction becomes
damaged. This is usually a result of severe
vomiting.
3. D Acute-onset bloody diarrhoea in a previously
fit person is most likely due to infective colitis.
Inflammatory bowel disease is also a possibility;
however, D is the most likely diagnosis in this
case.
4. A Portal vein thrombosis is a known complication
of splenectomy. Portal vein thrombosis can
lead to portal hypertension and therefore
development of oesophageal varices.
5. C Angiodysplasia is a condition where small
vascular malformations are present in the GI
tract. The colon is the most common site.
Bleeding can be intermittent, and OGD and
colonoscopy findings can be normal.
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EMQ answers
Chapter30 Renal, genitourinary and sexual
health medicine
Haematuria
1. C This is pyelonephritis given systemic features
of sepsis along with loin tenderness. Acute
cystitis would give irritative urinary symptoms of
frequency and dysuria but systemic features of
sepsis would not be present.
2. H Visible haematuria with a history of weight
loss should ring alarm bells. The presence of a
varicocele indicates possible tumour spread to
the left renal vein. Remember the venous drainage
of the left testicle. In addition to this, renal cell
carcinomas can cause fevers, and can produce
erythropoietin, resulting in polycythaemia.
3. I The presence of upper airway symptoms and
signs implies this is polyangiitis with granuloma
rather than one of the other ‘pulmonary–renal’
syndromes. The causes of pulmonary–renal
syndrome include ANCA vasculitis and
Goodpasture syndrome.
4. F Colicky loin to groin pain suggests ureteric
obstruction. The passage of a renal calculus
down the ureter is the most likely cause of
these symptoms. Dehydration predisposes to
stone formation.
5. E These obstructive prostatic symptoms of
nocturia, poor stream and nocturnal dribbling
would tend to favour benign prostatic
hypertrophy, which has a greater tendency to
affect the urethral part of the prostate. However,
the back pain is a sinister feature and points
towards the presence of bony metastases,
making prostatic carcinoma the best answer.
Renal impairment
1. I This can be inherited in an autosomal dominant
or autosomal recessive manner. The latter tends
to present earlier in childhood with development
of renal and liver cysts. Most cases are inherited
in an autosomal dominant manner. The disease
is characterized by the formation of cysts, which
grow in number and size over time. This leaves
little functioning renal tissue, with renal failure
ensuing. Complications also arise from the large
size of the organs. Cyst rupture, infected cysts, loin
pain and haematuria are frequent complications
of the disease. There is an association with
subarachnoid haemorrhage, mitral valve prolapse,
liver cysts and malignant change.
2. D This is an ANCA-associated vasculitis.
Cytoplasmic ANCAs or antibodies against
the PR3 antigen are generally present. It has
a predisposition of affecting the respiratory
system and kidneys (e.g., with epistaxis, nasal
crusting and haemoptysis). It is treatable with
aggressive immunosuppression. It can relapse,
so immunosuppression needs to be tapered
slowly with careful monitoring.
3. G This would be an AA amyloidosis, due to the
chronic inflammation. AA amyloidosis can be
caused by chronic inflammation from deposition
of serum amyloid A protein (SAA) an acute
phase protein. Amyloidosis is a multisystem
disease with the deposition of disordered
amyloid fibrils. In the gastrointestinal tract this
can lead to impaired absorption and diarrhoea,
and a nephrotic syndrome with deposition of
amyloid in the kidneys.
4. B Iodinated contrast agent is used with CT scans
to get better images. Contrast nephropathy is
more common in those with diabetes mellitus
and preexisting renal disease. It classically
causes an AKI after 72 hours. Where possible,
avoid use of contrast agent in these patient
groups. If imaging with contrast agent is
necessary, give hydrate the patient with
intravenous fluids, such as normal saline, before
and after imaging.
5. A There are several possible causes of
renal impairment in myeloma, including
hypercalcaemia, NSAIDs, amyloidosis and
light chain deposition. Myeloma can cause
anaemia, bone pain from bone infiltration and
predisposition to infection.
Disturbance of micturition
1. C A profound metabolic acidosis could occur in
diabetic ketoacidosis, severe septic shock, after
ingestion of toxins such as antifreeze (ethylene
glycol) and acute kidney injury. The most likely
answer here diabetic ketoacidosis, which
requires a high glucose level, the presence of
ketones and acidosis to make the diagnosis.
This degree of acidosis would not be expected
in chronic kidney disease.
2. E Sarcoidosis is the most likely cause of
bilateral hilar lymphadenopathy in a young
man, and hypercalcaemia is a complication.
Hypercalcaemia can cause polydipsia and
polyuria. Other complications of hypercalcaemia
include renal calculi, abdominal pain, constipation
and confusion/psychiatric disturbance.
Remember ‘stones, bones, moans and groans’.
3. B Nephrogenic diabetes insipidus is a
complication of lithium treatment. Other
common causes of nephrogenic diabetes
insipidus include hypercalcaemia and
hypokalaemia.
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EMQ answers
4. E These would be the characteristic findings of
multiple myeloma, which is often complicated by
hypercalcaemia.
5. J It is important in the history to distinguish
frequency from polyuria.
Renal disease
1. F This describes nephrotic syndrome. The most
common cause of nephrotic syndrome in
children is minimal change disease. Most cases
in children respond well to steroid treatment.
2. D IgA nephropathy can present with visible
haematuria a few days following an upper
respiratory tract infection. This is in contrast
to a poststreptococcal glomerulonephritis,
where antigens are deposited in the glomeruli
and immune complexes form in situ, giving
a nephritic syndrome a few weeks after
the infection. Most IgA disease involves
nonvisible haematuria. Patients who have this
in combination with proteinuria, hypertension
or renal impairment are at greater risk of
progressive renal impairment.
3. C HIV-associated nephropathy shows a
characteristic collapsing FSGS on renal
biopsy. The presentation tends to be with
hypertension and nephrotic range proteinuria,
(i.e., >3 g in 24 hours); however, oedema and
hypoalbuminaemia are rarely seen. Treatment
is directed at treating the underlying HIV
infection. HIV can also cause a thrombotic
microangiopathy. Some treatments for HIV
infection can be associated with renal disease,
such indinavir, a cause of renal calculi.
4. J Polyangiitis with granulomas is an ANCAassociated vasculitis which can affect the upper
respiratory tract. Watch out for pulmonary
haemorrhage. The presence of pulmonary
haemorrhage is a poor prognostic feature,
and should be treated with plasma exchange
in addition to other immunosuppressive
treatments.
5. G Myeloma can cause ‘CRAB’, hypercalcaemia,
renal impairment, anaemia and bone infiltration.
It can result in renal impairment through
hypercalcaemia, light chain deposition,
concomitant use of NSAIDs, AKI from infection
and amyloidosis.
Chapter31 Fluid balance and electrolyte
disturbances
Calcium problems
1. G Sarcoidosis is a cause of hypercalcaemia. It is
a multisystem disease and commonly has skin
and pulmonary manifestations. Bilateral hilar
lymphadenopathy is a classic feature that can
be seen on chest imaging.
2. D This woman has symptoms of hypocalcaemia.
The neck operation is likely to have been a
parathyroidectomy, now leading to her having
hypoparathyroidism.
3. F An incidental finding of this sort is likely
to be from primary hyperparathyroidism,
which would lead to increased calcium loss
from bone and potentiate renal phosphate
excretion.
4. H Renal impairment is associated with
secondary hyperparathyroidism. This is
an appropriate response to low calcium
level. Hyperparathyroidism occurs in renal
impairment through two main mechanisms.
Firstly decreased ability of the kidneys to
excrete phosphate. A high phosphate level
gives positive feedback to the parathyroid
gland, stimulating PTH production. Secondly,
with renal impairment vitamin cannot be
hydroxylated and activated. A low vitamin D
level can cause a low calcium level, through
reduced intestinal uptake of calcium, and there
are vitamin D receptors on the parathyroid
gland. Low vitamin D levels will not provide
negative feedback, hence potentiating further
parathyroid hormone release.
5. A Weight loss and sclerotic lesions in ribs on
chest X-ray suggest malignancy. Multiple
myeloma tends to give lytic bone lesions.
Prostate cancer metastasizes to bone and gives
sclerotic bone lesions.
Hyponatraemia
1. C She has hyponatraemia, a low glucose level
and one would expect, although not given in
the vignette, a high potassium level. Addison
disease often presents with very nonspecific
symptoms (e.g., with fatigue and abdominal
pain), although it can present as an Addisonian
crisis (see Chapter33). It is associated with
other autoimmune conditions.
2. H This is a pseudohyponatriaemia. Avoid
venepuncture near the cannula site where fluid/
medication is being administered.
3. B In accordance with National Institute for Health
and Care Excellence guidelines, the second-line
antihypertensive medication in patients older
than 55years would be a thiazide diuretic (e.g.,
bendroflumethiazide or indapamide). This is a
class of diuretic, and has a weak diuretic action,
but potent antihypertensive properties. Thiazides
are a common cause of hyponatraemia.
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EMQ answers
4. I Hypothyroidism can cause hyponatraemia.
Classic symptoms of hypothyroidism are poor
appetite, fatigue, cold intolerance, weight gain,
depression and constipation.
5. A Pneumonia can cause SIADH. However,
remember that SIADH is a diagnosis of
exclusion and can be diagnosed only in the
context of euvolaemia and normal thyroid,
adrenal, renal and liver function test results. The
diagnostic criteria include a low serum sodium
level, and an inappropriately high urinary sodium
level (>30 mmol/L) and a low plasma osmolality
and inappropriate high urine osmolality (e.g.,
>100 mOsmol/kg). The drugs in question do
not cause hyponatraemia.
Potassium disorders
1. J This is suggestive of renal failure. He has
symptoms of uraemia, with itch and metallic
taste. Biochemically this would fit with renal
impairment, with a low haemoglobin level
from reduced erythropoietin production by the
kidney, and high phosphate level from reduced
phosphate excretion, in addition to the raised
potassium level. One may also expect to see a
low bicarbonate level, low/normal calcium level
and raised PTH level. The cause suggested is
long-standing poorly controlled hypertension.
2. H Addison disease is likely in the context of
vague abdominal pains, hypotension and
blood test results showing a low sodium level,
raised potassium level and low glucose level.
Adrenal insufficiency can be diagnosed with a
random cortisol level test (the level would be
low) followed by a Synacthen test, in which the
synthetic ACTH would not cause an appropriate
rise in the cortisol level (see Chapter33).
3. I This gentleman is receiving Hartmann solution
intravenously. This fluid (crystalloid) is used as
both a resuscitation fluid and a maintenance
fluid. It contains potassium at a level of 5 mmol/L.
Be careful with checking serum potassium level
when you are administering Hartmann solution.
This elderly man has sepsis and is being given
gentamicin, a nephrotoxic medication (although
a good choice with pyelonephritis). He is at risk
of an acute kidney injury, which may also be
contributing to his hyperkalaemia.
4. E This woman has symptoms of sicca syndrome,
a feature of Sjögren syndrome. Sjögren
syndrome can lead to the development of a
renal tubular acidosis, both distal and proximal.
Distal renal tubular acidosis, also known as
‘type 1 renal tubular acidosis’, is associated
with hypokalaemia, nephrocalcinosis and
renal calculi. It is diagnosed with a systemic
acidosis in the context of an inappropriately
alkaline urine. This alkaline urine also favours
more calcium phosphate stone formation. The
learning point here is to measure the urinary pH
in an individual with an unexplained systemic
acidosis. Is it inappropriately alkaline?
5. D. This suggests a possible underlying renal artery
stenosis. Renal artery stenosis is commonly
seen in those with underlying vascular disease.
It often presents with difficult to control blood
pressure (often requiring more than four agents)
and oedema, and is associated with flash
pulmonary oedema. It should be considered
in individuals whose creatinine level rises by
more than 30% or whose estimated glomerular
filtration rate decreases by more than 25% after
treatment with an angiotensin receptor blocker
has been started. Renal artery stenosis can be
detected by renal ultrasound scan with Doppler
imaging or by magnetic resonance angiogram.
Chapter32 Nervous system
Headache
1. A This must be treated as suspected meningitis.
2. I Attacks of trigeminal neuralgia are often
triggered by innocuous stimuli.
3. F Clusters last 4–12weeks and are followed by
pain-free periods of months.
4. H Prompt therapy with steroids is required
to avoid permanent damage to her vision.
A temporal artery biopsy may confirm the
diagnosis but may be falsely negative because
of ‘skip lesions’.
5. C There is an increased incidence of subarachnoid
haemorrhage in polycystic kidney disease.
Altered level of consciousness
1. A The sudden onset suggests a vascular cause.
Loss of consciousness is uncommon in strokes
unless the brainstem is affected. This may
occur in brainstem stroke or from the pressure
effects of huge infarction or haemorrhage.
2. J The sudden onset again suggests a vascular
cause, and in this context the subhyaloid
haemorrhages are pathognomonic of
subarachnoid haemorrhage.
3. B The most likely explanation is an opiate
overdose. This could be assessed by giving the
patient naloxone (an opiate antagonist).
4. C Decompensated liver disease often causes
encephalopathy. It is often precipitated by infection,
constipation and gastrointestinal bleeding.
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EMQ answers
5. E Diuretic therapy is a common cause of
hyponatraemia, which in turn can cause an
altered mental state and seizures.
Cranial nerves
1. G Peripheral visual field loss is suggestive of
bitemporal hemianopia. This can be caused by
a lesion at the optic chiasm such as pituitary
adenoma, which in this case has also manifested
itself with features of growth hormone excess.
2. F Third nerve palsy may be caused by vascular
lesions in patients with diabetes. The pupil may
be spared.
3. A The other two features of Horner syndrome
are enophthalmos and anhidrosis. In this case
the cause is a preganglionic lesion—thyroid
neoplasm.
4. E Shingles of the geniculate ganglion.
5. I Diabetes is a common cause.
Seizures
1. G This is a typical history of complex partial
seizures seen in temporal lobe epilepsy. There
is an association with febrile convulsions in
childhood.
2. D A nonblanching rash in a child is always
meningococcal in origin unless proven otherwise.
Meningococcus is a common cause of meningitis.
3. C The incidence of alcohol excess is known to be
high in this social group.
4. B Early-morning headaches are suggestive of
raised intracranial pressure.
5. E Absence seizures are often described by
patients or observers as ‘vacant episodes’ or
‘episodes of unresponsiveness’. Spike wave
activity is commonly seen on EEGs of patients
with this condition.
Miscellaneous neurological disorders
1. F Symptoms suggestive of myasthenia gravis.
2. C Guillain–Barré syndrome is commonly
precipitated by a viral illness. These are the
clinical features.
3. A Features are of an inflammatory myopathy (e.g.,
polymyositis).
4. H Common peroneal nerve palsy—the peroneal
nerve is susceptible to entrapment and injury.
5. I Dorsal column disease occurs in vitamin B12
deficiency and advanced syphilis.
Nerve lesions
1. D Chronic lead poisoning causes gastrointestinal,
neuromuscular and neurological signs
and symptoms. Abdominal pain is very
common. Long-term exposure causes axonal
degeneration, which results in development of
neuropathies that present similarly to those of
alcohol abuse or diabetes.
2. I Loss of vibration sense and proprioception
with the upper motor neurone sign indicates
involvement of neurones of the dorsal column
pathway.
3. G Pancoast tumour is cancer that is located in the
apex of the lung. It can cause a compression of
a range of structures passing through the area,
resulting in a range of symptoms. Compression
of the brachial plexus can cause upper limb
muscles weakness or sensory disturbances
(including pain). Sympathetic ganglion
compression can cause Horner syndrome.
4. J Cape-like distribution of sensory abnormalities
resulting from compression of the spinothalamic
tract. This is most commonly caused by a fluidfilled cavity within the spinal cord. Classically, other
sensory modalities are spared in this condition.
5. A This is compression of the median nerve when
it passes through the carpal tunnel at the wrist.
Most cases are idiopathic.
Headache
1. A This is a classic presentation of a cluster
headache.
2. I Tension headache is commonly described as
a feeling of a tight band around the head. The
headache is constant and it can last for weeks.
3. G Anyone presenting with nontrauma-associated
sudden onset severe headache, especially
to the back of the head, has a subarachnoid
haemorrhage unless proven otherwise.
Hypertension is a risk factor.
4. F Tenderness over the forehead may also be
present in tension headache. In sinusitis there
are usually nasal symptoms.
5. B Giant cell arteritis is a form of vasculitis that
typically affects medium-sized and large arteries
of the head. It is a serious condition that
can lead to blindness, and as such requires
immediate treatment. Management includes
high-dose steroids.
Transient loss of consciousness
1. H Cardiac arrhythmia is the most common
cause of cardiac syncope. Usually there
is no prodrome and the patient regains
consciousness fairly rapidly. In a young patient
such as this one, the presence of congenital
cardiac abnormalities should be excluded.
2. D The most likely cause here is postural
hypotension. The patient’s blood pressure
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EMQ answers
drops, causing hypoperfusion of the brain, after
she stands up from the supine position too
quickly.
3. F Aortic stenosis produces an ejection systolic
murmur radiating to the carotids. The
murmur is exacerbated by expiration. Loss of
consciousness associated with aortic stenosis
typically occurs when the patient is standing or
on exercise.
4. A patient presenting with a focal neurological
symptom and new onset confusion needs to
be investigated for a possible stroke. As the
symptoms are yet to resolve, the diagnosis
cannot be a TIA.
5. I The patient is a known insulin dependent diabetic.
Although not impossible, it is more common
for epilepsy to present in younger or older age
groups. Hypoglycaemia can cause seizures, and
is the most likely diagnosis in this case.
Chapter33 Metabolic and endocrine
systems
Endocrine tests
1. D The suspected diagnosis is acromegaly. A
useful screening test is the IGF-1 level. If the
IGF-1 level is high, an oral glucose tolerance
test should be performed to confirm the
diagnosis of acromegaly. In health, the glucose
load would suppress GH to less than 1 ng/
mL; if this does not occur, the diagnosis of
acromegaly can be made.
2. F Investigations are directed at finding an
endocrine cause of suspected hypoglycaemic
episodes. The most common causes are from
hypoglycaemic agents (e.g., sulphonylureas).
It is important to test for adrenal failure (e.g.,
Addison disease). However, the only way
to exclude an insulinoma is to conduct a
prolonged fast and measure serum glucose
and C-peptide levels if symptoms occur.
C-peptide is produced from the breakdown of
proinsulin, and its level and will be raised only in
endogenous hyperinsulinaemia.
3. H Autoimmune Addison disease is
suspected. Administration of an exogenous
adrenocorticotrophic hormone (Synacthen)
is used to diagnose Addison disease. The
Synacthen test would fail to produce an
appropriate increase in serum cortisol level with
Addison disease.
4. J. His cranial diabetes insipidus will be
demonstrated by a failure to concentrate the
urine during a water deprivation test as the
serum osmolality rises. If desmopressin is
administered, the urine will concentrate within 1
hour as the renal tubules remain responsive to
antidiuretic hormone.
5. B Cushing syndrome is suspected and will be
confirmed if the administration of exogenous
steroids fails to suppress adrenal steroid
synthesis.
Clinical features in endocrine disease
1. E These features are in keeping with Addison
disease. Increased pigmentation suggests
primary adrenal failure with high levels
melanocyte-stimulating hormone produced
alongside high levels of adrenocorticotrophic
hormone. Biochemical features include
hyperkalaemia, hyponatraemia and
hypoglycaemia.
2. H Secondary to long-term steroid use in this
case. This is termed ‘Cushing syndrome’.
Other causes could be from ectopic
adrenocorticotrophic hormone (ACTH)
production or cortisol-producing adenoma.
‘Cushing disease’ is used to describe an ACTHproducing pituitary tumour.
3. A Phaeochromocytoma is the most likely cause
here. It can present insidiously or in extremis
and imitate severe sepsis, acute coronary
syndrome or cardiogenic shock.
4. F An aldosterone-producing adenoma,
Conn syndrome, causes hypertension
and is associated with hypokalaemia, mild
hypernatraemia and metabolic alkalosis. It
should be considered
as a differential in individuals with resistant
hypertension. The hypokalaemia often causes
muscle symptoms.
5. G A pharmacological cause of gynaecomastia.
Examples of other causes include
spironolactone, oestrogens and cimetidine.
Liver disease and diabetes are other causes of
gynaecomastia. A prolactinoma would cause
testicular atrophy and galactorrhoea but not
gynaecomastia.
Metabolic bone disease
1. C Osteoporosis classically affects White and Asian
postmenopausal women. Low oestrogen levels
and steroid use are the strongest risk factors.
This woman, having amenorrhoea and likely
low body mass index, is at risk of osteoporosis.
Other significant risk factors are smoking, family
history, alcohol, caffeine and immobility.
2. B The vignette is suggestive of coeliac disease, a
rash suggestive of dermatitis herpetiformis and
abdominal pain following a diet rich in gluten.
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