THE UNIVERSITY OF SHEFFIELD SCHOOL OF MEDICINE
LEVEL 5 INTEGRATED EXAMINATION MAY 2000
SHORT ANSWER QUESTION PAPER
MODEL ANSWER - QUESTION 1
A 38 year old female patient was admitted as an emergency. Site had been complaining
of increasing left-sided loin pain over the past week. Over the previous 24 hours she
started to feel unwell, sweaty and faint. She had no significant past medical history. On
examination, she looked flushed and uncomfortable. Her temperature was 39.4 °C and
on palpation she was tender in the left loin.
Wliat is the most likely diagnosis?
• Acute left pyeionephritis (accept acute pyelonephrosis, upper urinary tract
infection, infected, obstructed kidney, pyonephrosis, perinephric abscess)
Wliat immediate investigations would you recommend?
• MSU - microscopy, culture, sensitivity
• FBC
• U&E, creatinine
• Urine - protein, urinary electrolytes and creatinine
• Blood culture
• Blood glucose (to exclude diabetes}
• Pregnancy test (pyelonephritis more common in pregnancy)
Wliat are the principles of treatment?
• Wide spectrum antimicrobials initially - any of the following are suitable:
Ciprofloxacin or other quinolone, Cefuroxime, Cefotaxime or other third generation
cephalosporin, augmentin, piperacillin-tazobactam, gentamicin or any other
aminoglycoside)
• Septrin, co-trimoxazole not suitable for upper urinary tract infection
• Further antibiotic therapy as indicated by sensitivities
• Hospital admission and TV treatment may be needed but is not routinely
necessary -an otherwise haemodynamically healthy patient could be managed on an
outpatient basis with oral ciprofloxacin
• Follow-up urine culture
• Analgesia - e.g. paracetamol, codeine, occasionally require stronger analgesia e.g.
opiates. Avoid non-steroidals (nephrotoxicity)
• Hydration - possibly W fluids
• If failure to respond within 48 hours of treatment, referral to Urologist for
investigation of underlying cause - plain abdominal X-ray, abdominal USS, possibly
intravenous pyelography
• At this age, the likeliest underlying cause is stone or pelvi-ureteric junction
obstruction. Other obstructive causes, reflux and congenital anomalies e.g. duplex
collecting systems should be considered
• May need percutaneous nephrostomy under local anaesthesia or more definitive
surgical treatment.
THE UNIVERSITY OF SHEFFIELD SCHOOL OF MEDICINE
LEVEL 5 INTEGRATED EXAMINATION MAY 2000
SHORT ANSWER QUESTION PAPER
MODEL ANSWER - QUESTION 2
A 45 year old man presented with weight gain and bruising. On examination, he had
centripetal obesity, thin skin, bruising and a proximal myopathy,
What is the diagnosis?
• Cushing's syndrome
What are the causes?
• Pituitary dependent e.g. adenoma (Cushing's disease)
• Adrenal dependent e.g. tumour, benign (adenoma) or malignant (adenocarcinoma)
• Ectopic ACTH secretion (e.g. carcinoma lung, bronchial carcinoid)
• Steroid treatment (for asthma, eczema etc.)
Describe how you would investigate the patient to determine the underlying cause?
• Two phases:
1. Confirm the diagnosis.
Cushing's is an abnormality in the circadian rhythm of cortisol secretion, with loss of
diurnal rhythm and an abnormality in feedback with loss of dexamethasone
suppression.
Therefore, low dose dexamethasone suppression test or overnight dexamethasone
suppression test (1mg given last thing at night, cortisol measured in the morning). In
normal person, cortisol will be less than 50. Greater than 50 indicates Cushing's
syndrome,
2. Determine the cause.
Measure ACTH.
If detectable, suggests ACTH-dependent Cushing's, either due to pituitary cause or
ectopic secretion. Inferior petrosal sinus sampling, followed by pituitary imaging.
Chest X-ray
If undetectable, likeliest cause is adrenal tumour. Imaging - MRI, CT scan adrenals
THE UNIVERSITY OF SHEFFIELD SCHOOL OF MEDICINE
LEVEL 5 INTEGRATED EXAMINATION MAY 2000
SHORT ANSWER QUESTION PAPER
MODEL ANSWER - QUESTION 3
A 60 year old man with angina rang his GP surgery to order more GTN sprays as he
had been using the sprays much more frequently than usual over the last two weeks.
He complained that he had woken for three consecutive nights with angina and could
not walk to the telephone without pain.
What should the GP do?
• Advise patient to rest - visit immediately, perhaps having already arranged emergency
admission
• Aspirin if not already taking it - SOOmg
• Arrange urgent admission to hospital - CCU
Wfiat is the diagnosis?
• Unstable or crescendo angina
• Need to exclude Ml
What treatment should the patient receive?
• Maxima! anti-anginal therapy whilst being investigated (ECG, cardiac enzymes) to
exclude MI
• IV nitrate
• Beta-blocker if no centra-indication - to achieve a bradycardia of 60
• Calcium channel blocker
• K-channel opener (nicorandil)
• Aspirin if no centra-indication - anti-platelet activity
• Clopidogrel if intolerant of aspirin
« IV Heparin in full dose or weight adjusted low molecular weisht treatment (SC
Img/Ks bd)
• Check cholesterol - treat if over 50
• Bed rest
• Referral to cardiologist
• Coronary angiography with a view to possible early surgical intervention e.g.
angioplast? +/-stentingofCABG
• He may need advice on smoking cessation, diet, life style etc.
What are the possible outcomes of this condition?
• Resolution - better than 50% chance that the patient will be pain-free within 24-48
hours.
• Persistent unstable angina
• MI
• Death (untreated risk is about 15%)
THE UNIVERSITY OF SHEFFIELD SCHOOL OF MEDICINE
LEVEL 5 INTEGRATED EXAMINATION MAY 2000
SHORT ANSWER QUESTION PAPER
MODEL ANSWER - QUESTION 4
A 57 women previously treated by wide local excision, radiotherapy and Tamoxifen for
carcinoma of the breast presented with pain in the left thigh. She described the pain as
an aching in the left thigh, which was exacerbated by bearing weight and was
associated with local tenderness. Plain X-ray of the left leg revealed a sclerotic lesion
in the proximal shaft offetmir and an isotope bone scan showed multiple nietastases, U
& E, full blood count and serum calcium were normal.
Briefly outline the therapeutic options for the treatment of her breast cancer.
• Care is essentially palliative - the patient's wishes are paramount
• Aim of treatment is to relieve pain (see below) and to prevent pathological fracture
• Full metastatic screening - LFTs, CXR, liver USS
• Local radiotherapy - single dose
« May stabilise the femur with intramedullary nailing with locking screws to give
rotational stability and prevent telescoping « May pack site of metastasis with
methylmethacrylate bone cement (possibly with inclusion
of chemotherapeutic agents into the bone cement) « Check oestrogen status of original
tumour. Consider changing hormone therapy
(Megestrol Acetate, Anastrozole) +/- more intensive hormone manipulation e.g.
oophorectomy
• Palliative chemotherapy. May hold in reserve for symptomatic disease. High dose
chemotherapy may offer some survival advantage
• Refer to oncologist/palliative care physician
Briefly outline the therapeutic options for controlling her pain,
• Bone paia difficult to treat
• Non-steroidal anti-inflammatories
• Opiate analgesia - e.g. morphine sulphate - regular doses, slow release
• Diamorphine elixir for breakthrough pain
• Biphosphonates IV - oral
• Local radiotherapy
• Steroids
• Chlorpromazine
• SC calcitonin
• Anaesthetic and/or neurosurgical procedures
• Control symptoms which may result from treatment e.g. constipation, nausea
THE UNIVERSITY OF SHEFFIELD SCHOOL OF MEDICINE
LEVEL 5 LNTEGRATED EXAMINATION MAY 2000
SHORT ANSWER QUESTION PAPER
MODEL ANSWER - QUESTION 5
You are a public health physician. Local television news has recently reported the
results of a case-control study linking electromagnetic fields to childhood leukaemia.
As there are several high voltage power lines in the area, a local newspaper has
approached you to try to explain the significance of this study.
Wimt measure of association is likely to have been used in a case-control study? •
Odds ratio
List and briefly explain three reasons that could account for apparent associations,
where none truly exist, in epidemiologlcal studies?
1. Bias - a systematic error that leads to a departure from the truth e.g. selection bias in
selection of cases or controls, measurement bias in obtaining details of exposure to
electromagnetic fields.
2. Confounding - a situation in which a variable is associated with the exposure of
interest (e.g. electromagnetic fields) and independently influences the outcome (e.g.
leukaemia) but does not lie on the causal pathway. This confounding variable may not be
known or has been inadequately adjusted for in the study.
3. Chance - random variation.
List and briefly explain Jive criteria that you could use to judge if an association is
likely to be causal.
1. Strength of association - a strong association (i.e. large relative risk) is more likely to
be causal than a weak association.
2. Biological plausibility - the association is more likely to be causal is there are
plausible biological mechanisms e.g. from animal experiments or in vitro studies.
3. Dose response - increasing levels of exposure are associated with higher risks of the
disease.
4. Temporal relationship - exposure precedes the disease.
5. Reversibility - when the removal of the cause results in a reduced disease risk, the
likelihood of the association beine causal is strengthened.
THE UNIVERSITY OF SHEFFIELD SCHOOL OF MEDICINE
LEVEL 5 INTEGRATED EXAMINATION MAY 2000
SHORT ANSWER QUESTION PAPER
MODEL ANSWER - QUESTION 6
Question 6
A 58 year old male was referred to hospital by his GP. A few days prior to admission,
lie had woken with speech disturbance and heaviness in the right arm which had not
resolved on admission. He had smoked 20 cigarettes a day for most of his adult life. He
also had hypertension for which he was being treated with EnalapriL
What is the most likely diagnosis?
• Cerebral infarction
What other diagnoses should be considered?
• Primary intracerebral haemorrhage
• A space occupying lesion
• Post-ictal paralysis following an epileptiform seizure
• Acute sub-dural haemorrhage
• Encephalitis
• Hemiplegic migraine
What is the likely cause?
• Atheroma and thrombo-embolic disease
• Other causes include hypertensive small vessel disease, carotid artery dissection ant
embolism as a result of mural thrombosis in atrial fibrillation.
THE UNIVERSITY OF SHEFFIELD SCHOOL OF MEDICINE
LEVEL 5 LNTEGRATED EXAMINATION MAY 2000
SHORT ANSWER QUESTION PAPER
MODEL ANSWER - QUESTION 7
A 76 year old male with a history of angina and intermittent claudication presented to
the Renal Unit with hypertension (200/1 OOminHg). Previously, he was admitted on a
few occasions with sudden onset dyspnoea reflecting pulmonary oedema. He was
recently started on a new antihypertensive agent (the name of which he forgot) in
addition to his diuretic, beta and alpha blockers. Since he was started on this new drug,
his renal function deteriorated. Investigation showed his renal function tests to be
abnormal (urea 23 mmol/L, creatinine 3
W]iat is the likely cause of his hypertension?
• Renovascular disease, probably bilateral renal artery stenosis secondary to
atherosclerosis
What is the nature of the antihypertensive agent that affected his renal function?
• ACE inhibitor (couid be angiotensin receptor antagonist)
What clinical signs would you look for to substantiate the diagnosis?
• Bruit over renal artery (i.e. posteriorly) - but rare
• Signs of generalised peripheral vascular disease including other bruits (abdominal,
femoral etc.) and peripheral pulses. Cutaneous signs of peripheral vascular disease.
• Predominantly systolic hypertension/wide pulse pressure
• Optic fundi - retinopathy
• Heart and lungs - left ventricular failure
• Oedema
How would you conflrmyour clinical diagnosis?
• Renal artery angiogram - probably gofd standard
• Withdraw the ACE inhibitor and monitor for recovery
• Magnetic resonance angiography
• Captopril renogram
• Rapid sequence intravenous pyelography
• Ultrasound
• Spiral CRT
• Renal duplex scanning
• Isotope renal scan
• Exclude renal infection
How would you manage this patient?
• Stop ACE inhibitor
• Monitor renal function - daily U&E, blood gases on admission (acidosis), repeat i:
deteriorating
• Monitor fluid balance - fluid balance chart, JVP - treat pulmonary oedema.
• Avoid other nephrotoxic drugs e.g. non-steroidai anti-inflammatories
• Control BP with other antihypertensive agents e.g. IV nitrates and bed rest
• Balloon dilatation of renal artery may be indicated
• Surgery (angioplasty +/- stent) may be indicated
• Nephrectomy
THE UNIVERSITY OF SHEFFIELD SCHOOL OF MEDICINE
LEVEL 5 INTEGRATED EXAMINATION MAY 2000
SHORT ANSWER QUESTION PAPER
MODEL ANSWER - QUESTION 8
A 27 year old male, who is a member of the national climbing team fell from Stanage
Edge in Derbyshire. He fell 22 feet and sustained obvious injuries to both his ankles.
These are closed injuries with deformity and swelling. Wlten he arrived in the A&E
Department, he was talking clearly but was In a great deal of pain and was shouting
for pain relief. His pulse rate was 1 OSbpm and his blood pressure, which was taken in
a supine position, was 120/70 mmHg. Respiratory rate was 16 per min.
Wliai is the initial management?
• Use full ATLS protocols - history from patient, ambulancemen, other observers.
• Swift assessment of vital functions - ABCDE
• IV cannuiae - large bore, preferably two
• Protect spine until injury excluded
• Blood for cross-match (and baseline investigations as below)
• Monitor pulse, BP, respiratory rate etc.
• Give IV analgesia
• Examine ankles for dislocation, feet for neurovascular damage, reduce as necessary
using IV analgesia +/- Entonox, splint fractures
• Full examination - anticipate other injuries in the long axis - long bones of legs,
pelvis and spine
• IV fluids
• Give oxygen - monitor pulse oximetry
From the above details, is there any evidence of significant hypoxia and/or
hypovolaemia?
• At present, the airway is patent and breathing is not compromised (the patient is
shouting)
• His higher cerebral functions are adequate therefore there is no evidence of
significant hypoxia
• However, the pulse rate is high and, in a fit individual, should be low. Therefore this
is a significant tachycardia indicating that he may be bleeding
• It is unlikely that the ankle injuries are sufficient to account for hypovolaemia
• Examination should therefore be directed at detecting concealed sources
of haemorrhage - chest, abdomen, pelvis
• Pain may be contributing to the tachycardia
Wliat investigations would vou perform?
• Baseline FBC
• U&E
• Urina lysis
• X-ray - ankles
• Other X-rays as indicated by examination e.g. chest, pelvis, spine, long bones in
leg etc.
• Amylase