1.
A 34 year old man presents to the emergency department in excruciating abdominal pain. It woke him from sleep about one hour ago and he now has severe right
lower quadrant pain radiating into his testicle. He is nauseated and
has vomited twice in the past hour. The pain is not relieved in any
position, and he has never experienced anything like this before. What should be asked or performed next?
Correct Answer
A. Past medical history
Explanation
Medical history consists of hospital or GP treatment
surgery or any anaesthetic problems
MI / IHD / CVA / TIA / ep / asth / TB / liver / pu / DM / rhF / bp
medications and allergies, any side effects, previous medical therapies
2.
After further history taking, he
has type 1 diabetes but claims it is well controlled. His only
medication is insulin, and he has no allergies.What should be done next?
Correct Answer
D. Vital signs
Explanation
Vital signs should always be done first before any invasive procedures.
3.
Abdomen: soft, bowel sounds present, right-sided tenderness worse in upper quadrant
Genitalia: uncircumcised phallus, non bloody meatus, non tender descended testis
Rectal: normalThink about your differential diagnosis, then reveal the options and choose the one most likely diagnosis.
Correct Answer
B. Acute renal colic
Explanation
Pain that radiates "from loin to groin" is a classic presentation for renal colic. Nausea and vomiting are almost always present because the kidney shares autonomic innervation with the gastrointestinal tract. The abdomen is typically soft with mild tenderness on the affected side, and ileus may occur in protracted cases. Signs of peritonitis are rare.
4.
Choose the initial investigation which is not helpful to confirm your suspected diagnosis from the last question
Correct Answer
C. IV pyelogram
Explanation
Unenhanced CT is the preferred imaging modality, since essentially all stones show up on CT. IV pyelogram allows visualization of the degree of obstruction, but it is time consuming and requires contrast that cannot be administered until it is established that the patient does not have pre-existing renal failure (thus the creatinine).
An elevated leukocyte count may suggest urinary tract infection, which necessitates more aggressive intervention or admission. Urine pH may help determine the type of stone (acidic pH suggests uric acid stone, alkaline pH suggests infective or struvite stone). Gross or microhematuria is often seen.
5.
CT reveals a stone 4 mm in diameter in the right distal ureter.
The lab results are as follows:
Blood:
- WBC 9,600/uL (4,000-10,000)
- BUN 11 mg/dL (8-20)
- creatinine 1.0 mg/dL (0.7-1.3)
Urinalysis:
- specific gravity 1.040
- RBC: 60-100/hpf
- no bacteria
- pH 5
Your initial management includes all this except:
Correct Answer
C. Admission to hospital
Explanation
Stones less than 5 mm in diameter will pass spontaneously 75% of the time. Therefore, this patient can be managed on an outpatient basis with oral hydration, oral pain control, and urine straining. Retrieval of the stone or stone fragments allows for analysis that can guide future preventative measures.
Admission criteria include: inability to tolerate oral hydration or pain control, evidence of infection, renal failure, or solitary kidney.
6.
Which of the following is FALSE regarding renal colic?
Correct Answer
D. Urinary extravasation is an operative indication
Explanation
Urinary extravasation is inconsequential.
Remember these key points about renal colic:
1. presents as intense pain radiating from loin to groin with nausea and vomiting
2. diagnosed by CT scan
3. management is usually outpatient oral hydration and pain control until the stone passes spontaneously
4. admission indications include: compromised renal function, inability to tolerate outpatient management, evidence of infection
7.
A 12 year old boy with Crohn's disease presents to the ER with an acute
abdomen. The pediatric ER physician completes a complete workup and
diagnoses the boy with a small bowel obstruction. Medical management
was unsuccessful and he underwent surgical resection of the ileum.
Which of the following nutritional deficiencies is he now at risk for?
Correct Answer
A. Vitamin B12 deficiency
8.
A three month old infant, Jason, presents with irritability. Mom
describes him to be "incredibly fussy and always crying". He is
difficult to settle down to sleep and if placed on his back he will not
stop crying until held or rolled onto his stomach. It is impossible to
go anywhere in the car because he "hates his car seat and won't stop
screaming". He has been irritable since birth but it wasn't until about
3 weeks ago that she began to worry. Mom is exasperated and does not
know what to do.
Upon further questioning you discover that Jason only likes to be held
on his side or in a vertical position, not cradled horizontally. He is
feeding from one or both breasts every 2-3 hours however after he is
done mom finds that he is continually swallowing and arching his back.
In addition he often vomits a small amount after feeds. He has no signs
of respiratory distress. Jason's growing along the 50th percentile for
height and weight.
Mom had a normal pregnancy with no significant prenatal history or
complications during or after delivery. Jason is an otherwise healthy
baby.
What is the most likely diagnosis?
Correct Answer
B. Gastroesophageal reflux disease
Explanation
Gastroesophageal reflux disease is extremely common in infancy and may present with [non-bilious] vomiting after feeding, irritability, arching of the back and feeding problems. Further investigation may be required if the infant presents with failure to thrive, blood in the vomitus, recurrent cough, pneumonia or persistent symptoms. Management may include a trial of prevacid, frequent smaller feeds and positional changes.
9.
A 23-year old woman has been seeing her family doctor for crampy
abdominal pain and constant diarrhea, which is occasionally bloody. She
says the pain is mostly in her right lower quadrant. She's lost about
15 pounds over the past year. Upon reviewing her labs in a follow up
visit, the doctor notices her erythrocyte sedimentation rate and
C-reactive protein are elevated. What would top your differential
diagnosis?
Correct Answer
D. Crohn's colitis
Explanation
CRP and ESR are markers of systemic inflammation, pointing to some sort of inflammatory process. Crohn's usually (50% of the time) affects the terminal ileum and cecum, found in the RLQ, and classically presents with symptoms like bloody diarrhea, pain and weight loss.
10.
What fat-soluble vitamin is administered to all newborn infants?
Correct Answer
D. Vitamin K
Explanation
Vitamin K is administered to all newborns to prevent the development of hemorrhagic disease of the newborn (HDN). Newborns are deficient vitamin K due to low stores at birth, low levels in breast milk and poor placental transfer. Most standard commercial infant formulas contain supplemental vitamin K therefore HDN is primarily a problem of exclusively breast fed infants.
Please see article on HDN: http://www.emedicine.com/ped/TOPIC966.HTM
11.
Aims and objectives of an AMS are these except...
Correct Answer
A. To promote secondary health care
Explanation
To promote primary health care
12.
What is the most common aetiology of albumin proteinuria?
Correct Answer
A. increased glomerular permeability
13.
An otherwise healthy 20 year old patient of yours visited
yesterday complaining of fever, sore throat, cough, and general
cruminess. He mentioned that his pee had been darker over the last
little while, but he didn't think much of it because it comes and goes
about once a year. What is the most appropriate diagnostic testing to do?
Correct Answer
B. Urinalysis
Explanation
Urine is showing the presenting illness, other tests than is done to support.
14.
He's back today to discuss his urinalysis (red cells, otherwise
bland) and blood work (unremarkable). Thankfully, you called a
nephrologist buddy of yours who told you to...
Correct Answer
C. diagnose IgA nephropathy and monitor with urinalysis/renal function testing (GFR)
Explanation
BIG NOTE: IgA nephropathy is actually much more common in males, but I noticed that after writing the question. It has a widely variable clinical course, but in an otherwise healthy patient (normotensive) with isolated hematuria, it's usually quite benign. I think the most sensible thing to do would be monitoring his risk factors (BP, proteinuria) for progression to renal failure.
15.
These are all management for stress incontinence except...
Correct Answer
D. Drinking less water
16.
In patient centered management of chronic disease, the important aspects are these except...
Correct Answer
D. Integration of care provided by the doctor
Explanation
D. Integration of care provided by all professionals (FALSE)
17.
What are not the secondary causes of osteoarthritis of the hip?
Correct Answer
D. Idiopathic
Explanation
Idiopathic is the primary cause of osteoarthritis of the hip.