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Correct Answer: C) Atherosclerotic plaque rupture

Explanation:

This patient presents with severe chest pain, diaphoresis, and ST-segment elevation in the leads corresponding to the left anterior descending artery (V1-V4), indicating acute coronary syndrome (ACS). Given his recent coronary angiography and drug-eluting stent placement, stent thrombosis is the most likely cause of his current condition.

Stent thrombosis is a common cause of acute ST-segment elevation myocardial infarction (STEMI), particularly in the first 6-12 months following the placement of a bare-metal or drug-eluting stent. The risk is highest when dual antiplatelet therapy (DAPT) is not properly followed. In this patient, medication nonadherence (potentially due to financial constraints) is a strong consideration, given his uninsured status and the fact that DAPT is critical for preventing stent thrombosis.

Incorrect Answers:

• A) Acute pericarditis: This condition typically presents with pleuritic chest pain, pericardial friction rub, and diffuse ST-segment elevation on ECG. While this patient has ST-segment elevation, it is localized to the anterior leads (V1-V4), corresponding with his recently stented left anterior descending artery. Acute pericarditis would not be expected to cause this pattern of ECG findings or crushing chest pain.
• B) Aortic dissection: This condition presents with sudden-onset, tearing chest pain that radiates to the back and is often associated with severe uncontrolled hypertension. ST-segment elevation is rare and only occurs if the dissection extends to the coronary arteries. The ECG findings in this patient are more consistent with STEMI than with aortic dissection.
• D) Left ventricular aneurysm formation: This is a potential complication of acute myocardial infarction that can develop over several months, not days, and typically causes persistent ST-segment elevation and heart failure symptoms. The patient’s chest pain and ECG findings are more consistent with acute stent thrombosis rather than a ventricular aneurysm, which usually manifests much later after a transmural infarction.
• E) Medication nonadherence: While medication nonadherence is indeed a risk factor for stent thrombosis, it is not the direct cause of this patient’s symptoms. The stent thrombosis caused by poor adherence to dual antiplatelet therapy (DAPT) is the underlying issue here, making atherosclerotic plaque rupture (which leads to thrombosis) the most likely cause. Thus, the focus should be on correcting this issue by addressing DAPT adherence.

Learning Objective:

Dual antiplatelet therapy (DAPT) is crucial for preventing stent thrombosis in patients who undergo coronary artery stenting. The most common cause of stent thrombosis is poor adherence to or inability to take the prescribed DAPT, leading to acute coronary syndrome. It is important to counsel patients on the significance of consistent DAPT use, both at the time of stent placement and during follow-up.

1. Atherosclerotic plaque disruption
   This patient is presenting with signs of acute-on-chronic limb ischemia due to peripheral artery disease (PAD). PAD is a common cause of arterial occlusion, particularly in smokers and those with hypertension and hyperlipidaemia, as seen in this patient. His symptoms of pain at rest (worsening throughout the day), mottling, coolness, prolonged capillary refill, and difficulty moving the foot are all suggestive of compromised blood flow to the foot. Atherosclerotic plaque disruption in the popliteal artery can lead to thrombosis and acute ischemia, especially in the setting of preexisting PAD. Since the patient already has some collateral circulation, the classic “6 Ps” of acute limb ischemia (Pain, Pallor, Paresthesia, Pulselessness, Poikilothermia, and Paralysis) are not as pronounced but still present. Emergency intervention, such as heparin infusion, thrombolysis, or thrombectomy, is needed to restore perfusion.

Wrong Answer Explanations:

1. Exaggerated cutaneous vasoreactivity
   This condition is seen in Raynaud phenomenon, where vasoconstriction typically affects the fingers and is triggered by cold. It leads to color changes in the skin but is not associated with prolonged pain, mottling, or impaired blood flow as seen in this patient. The patient’s symptoms and clinical findings do not align with Raynaud’s phenomenon.
2. Increased compartmental pressure
   While compartment syndrome is a limb-threatening condition that can cause pain and paresis, it is usually associated with trauma (e.g., crush injuries, fractures) or after ischemia-reperfusion injury. It is also characterized by tense swelling and pain on passive stretch, which this patient does not exhibit. The absence of swelling and the history of PAD make compartment syndrome less likely.
3. Popliteal vein thrombosis
   Popliteal vein thrombosis more commonly causes symptoms of distal warmth and/or swelling due to decreased venous outflow, not coolness and prolonged capillary refill, which are associated with arterial insufficiency. This patient has signs pointing to arterial rather than venous occlusion.
4. Tobacco-associated vasculitis
   Tobacco-associated vasculitis (thromboangiitis obliterans) causes extremity ischemia, particularly in young smokers (<45 years) and often begins distally (e.g., digital ischemia) before progressing proximally. This patient is older, and his symptoms are more consistent with chronic PAD rather than vasculitis. The patient also has no history of digital ischemia, making this diagnosis unlikely.

Learning Objective:
Patients with preexisting peripheral artery disease (PAD) who develop acute-on-chronic limb ischemia typically present with more gradual onset of symptoms compared to those with acute arterial embolism. Collaterals may offer some perfusion, but emergency intervention is still required to prevent irreversible limb damage

Explanation:

This patient presents with syncope, weakness, dyspnoea, and chest discomfort. His medical history, including hypertension and a family history of coronary artery disease, along with the symptoms he is experiencing, suggest the possibility of cardiac tamponade.

Cardiac tamponade occurs when there is accumulation of fluid in the pericardial space, which can result from conditions such as pericardial effusion (due to malignancy, infection, or uremia) or trauma (such as left ventricular rupture). In this case, the patient’s symptoms, including weakness, dyspnoea, and chest discomfort, alongside the ECG findings of electrical alternans and low-voltage QRS complexes, suggest a subacute tamponade, likely caused by a pericardial effusion.

ECG findings like electrical alternans and low-voltage QRS complexes are indicative of cardiac tamponade, where the heart’s electrical signals are attenuated due to the fluid accumulation in the pericardial sac. Electrical alternans results from the heart’s changing position in the fluid-filled pericardial sac during each heartbeat.

Key diagnostic findings:

• ECG: Low-voltage QRS complexes and electrical alternans.
• Chest X-ray: Enlarged cardiac silhouette with clear lungs.
• Echocardiography: Right atrial and ventricular collapse, inferior vena cava (IVC) plethora.

The treatment for subacute tamponade is pericardiocentesis to drain the pericardial fluid and relieve pressure on the heart, thereby improving cardiac output. Intravenous fluids can also be administered to increase right-sided heart preload.

Incorrect Answers:

1. A) Adenosine

• Adenosine is used to treat certain types of supraventricular tachycardia, particularly atrioventricular nodal reentrant tachycardia (AVNRT). This is not appropriate for this patient’s symptoms, which point toward cardiac tamponade, not an arrhythmia.
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1. C) Amiodarone

• Amiodarone is an antiarrhythmic drug used for various arrhythmias, including atrial fibrillation or ventricular tachycardia. However, the patient’s primary issue is cardiac tamponade, not an arrhythmia. Thus, amiodarone is not the first-line treatment.
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1. D) Intravenous magnesium sulfate

• Magnesium sulfate is used to treat torsades de pointes, a specific type of polymorphic ventricular tachycardia typically caused by prolonged QT intervals. This patient’s symptoms and ECG findings are not consistent with torsades de pointes, making this treatment inappropriate.
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1. E) Synchronized cardioversion

• Synchronized cardioversion is used for acute conversion of certain arrhythmias (e.g., atrial flutter, atrial fibrillation). Since this patient’s issue is cardiac tamponade, synchronized cardioversion would not address the underlying problem and is therefore not appropriate.
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The most appropriate treatment for this patient is pericardiocentesis to relieve the pressure caused by the pericardial effusion, along with appropriate supportive measures like intravenous fluids to maintain cardiac output. The use of medications like amiodarone, magnesium sulfate, or adenosine is not indicated based on this patient’s condition.

Correct Answer:
E. Medication adverse effect

Explanation:
Digoxin toxicity is a well-known cause of various cardiac arrhythmias, including sinus bradycardia, junctional rhythms, and ventricular tachycardia. While many arrhythmias associated with digoxin toxicity can also occur in other clinical settings, atrial tachycardia with AV block is particularly specific for digoxin overdose and is considered diagnostic in patients taking the medication.

The cardiac effects of digoxin toxicity involve two primary mechanisms:

• Atrial tachycardia occurs due to increased automaticity in the atrial myocardium. The origin of the abnormal automaticity may be within the sinus node, producing P wave morphology similar to a normal sinus P wave, or within another part of the atrial myocardium, leading to a different P wave morphology. The atrial contraction rate typically reaches ~200/min, which is slower than atrial flutter (~300/min).
• AV block occurs due to increased vagal tone, leading to slowed conduction through the AV node. The block can be first-degree, second-degree (typically Mobitz type I), or third-degree. Mobitz type II second-degree AV block is rarely seen with digoxin toxicity.
• Additional arrhythmias can involve similar mechanisms, such as increased automaticity causing ventricular tachycardia or increased vagal tone leading to sinus bradycardia.

Furthermore, since digoxin competes with potassium at the myocardial sodium-potassium ATPase, hypokalemia can enhance digoxin binding, worsening toxicity or causing symptoms even at lower-than-expected serum digoxin levels.

Incorrect Answer Explanations:

• Choice A (Accessory conduction pathway): This is characteristic of Wolff-Parkinson-White (WPW) syndrome. WPW typically presents with a short PR interval and delta waves (slurred upstroke of the QRS complex) on ECG. It predisposes to AV reentrant tachycardia, which is distinct from this patient’s arrhythmia pattern.

• Choice B (Age-related cardiomyocyte fibrosis): Age-related fibrosis of the sinoatrial node is the primary cause of sick sinus syndrome, which presents with sinus bradycardia, sinus pauses, and sometimes sinus arrest. This patient’s ECG shows atrial tachycardia, which is not a typical feature of sick sinus syndrome.
• Choice C (Ischemic myocardial scarring): Myocardial scarring from a previous infarction increases the risk of monomorphic ventricular tachycardia (VT) due to reentrant circuits. This patient’s arrhythmia is atrial in origin, making VT less likely.
• Choice D (Left atrial enlargement): Left atrial enlargement, commonly seen in conditions such as long-standing hypertension or mitral valve disease, predisposes to atrial fibrillation rather than atrial tachycardia with AV block. Atrial fibrillation typically presents with an irregularly irregular rhythm without distinct P waves, unlike the ECG findings in this case.

Learning Objective:
Digoxin toxicity can induce a variety of arrhythmias due to increased automaticity in myocardial conduction and increased vagal tone. The combination of atrial tachycardia with AV block is highly specific for digoxin toxicity. Hypokalemia can potentiate digoxin effects, leading to toxicity at lower-than-expected serum level

This patient is presenting with symptoms and signs that are concerning for an acute aortic dissection (e.g., chest pain, syncope, pericardial effusion, history of hypertension, mediastinal widening on chest x-ray). Acute aortic dissection is a life-threatening condition that requires prompt diagnosis and management.

• CT angiography is the initial study of choice in hemodynamically stable patients with no evidence of renal dysfunction. It can help identify an intimal flap separating the true and false lumens of the aorta, confirming the diagnosis of aortic dissection. This imaging technique is rapid and non-invasive, making it ideal for initial assessment in stable patients.
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Incorrect Answers:

1. Antibiotics, fluid resuscitation, and admission to intensive care unit
   This patient’s presentation is more consistent with acute aortic dissection, not a bacterial infection like pneumonia or bronchitis. While antibiotics may be indicated in cases of infection, they are not appropriate for this clinical scenario, especially as there is no consolidation or infiltrate on the chest x-ray.
2. Beta blockers, anticoagulation, and admission to intensive care unit
   While beta blockers are typically used in managing acute aortic dissection to control blood pressure, the use of anticoagulation is contraindicated in this patient. The possibility of hemopericardium (blood in the pericardial space) makes anticoagulation risky. Additionally, initial diagnostic imaging with CT angiography is needed to confirm the diagnosis before starting treatment.
3. Cardiac catheterization
   Cardiac catheterization is used to diagnose coronary artery disease (e.g., myocardial infarction) but is not indicated here. The patient’s ECG shows left ventricular hypertrophy but no acute ischemic changes. Aortic dissection is a more likely diagnosis given his history of hypertension, chest pain, and pericardial effusion, which require a different diagnostic approach.
4. Immediate emergency pericardiocentesis
   Emergency pericardiocentesis is indicated in cases of cardiac tamponade caused by a large pericardial effusion with hemodynamic instability (e.g., hypotension, muffled heart sounds, distended neck veins). However, this patient is hemodynamically stable with a small pericardial effusion. The primary concern is aortic dissection, and diagnosing this is critical before performing procedures like pericardiocentesis.

Given this patient’s clinical presentation and risk factors, CT angiography is the most appropriate next step to confirm the diagnosis of acute aortic dissection. This condition requires prompt treatment to prevent life-threatening complications such as rupture or cardiac tamponade.

Spontaneous pneumothorax . is the most likely diagnosis given Mr. Adams’ sudden onset of dyspnoea, smoking history, decreased breath sounds, and hyperresonance on percussion. These findings are characteristic of pneumothorax, which can present suddenly and with hyperresonance. Acute bronchitis, asthma exacerbation, COPD exacerbation, and lung cancer would have different presentations and are less likely based on the clinical vignette.

A thorough assessment for emotional abuse is crucial, especially with behavioral and developmental concerns. Differential Diagnoses: 1. Emotional abuse; 2. Anxiety disorders; 3. Developmental disorders; 4. ADHD; 5. Social withdrawal due to peer issues; 6. Post-traumatic stress disorder; 7. Autism spectrum disorder. Incorrect Answers: B) Speech therapy addresses communication but does not address the broader concern of potential emotional abuse. C) Behavioral management and follow-up are secondary to the need for assessing and reporting emotional abuse. D) Psychological evaluation is important but should follow the immediate reporting of suspected abuse. E) Resources for anxiety and social skills do not replace the need for assessing potential emotional abuse.

The correct answer is- It is a normal pattern in the dying process. Cheyne-Stokes respiration is common in patients nearing the end of life and does not necessarily indicate distress. Differential diagnoses include end-of-life care issues, anxiety in family members, misunderstanding of medical processes, potential elder abuse, depression in family members, caregiver fatigue, and ethical dilemmas in palliative care.

Caring for a dying loved one can have a significant psychological impact on the family. Grief and sadness, anger and resentment, guilt and blame, and anxiety and depression are common emotions experienced by family members. It is important for the GP to be aware of these potential psychological impacts and to offer support and resources to the family.

Urgent referral for ENT assessment and imaging is the most appropriate next step given the unilateral symptoms, lack of allergy history, and presence of a unilateral nasal mass. Differential diagnoses include sinonasal malignancy, inverted papilloma, antrochoanal polyp, foreign body, and unilateral nasal polyp. A) Intranasal corticosteroids are unlikely to address the underlying cause of unilateral symptoms. B) Skin prick testing is not indicated given the lack of allergy history and unilateral presentation. C) Oral antibiotics are unlikely to be effective without clear evidence of bacterial infection. D) Saline nasal irrigation may provide symptomatic relief but will not address the underlying cause.

Explanation: Persistent abdominal pain, weight loss, and blood in stool warrant further investigation. A stool culture can identify infections, and an abdominal ultrasound can evaluate structural issues. Empirical treatment and dietary changes are less appropriate without a diagnosis. Colonoscopy might be needed later based on initial test results. Differential diagnoses include gastrointestinal infection, inflammatory bowel disease, peptic ulcer disease, gastrointestinal bleeding, irritable bowel syndrome, food intolerance, and malignancy.

Survival rates for acute lymphocytic leukemia have improved significantly. Billy has a better than 80% chance of cure with proper treatment.

The correct answer is- Normal bruising from toddler activity. Bruises on the shins are common in active toddlers and are usually not indicative of abuse. Differential diagnoses include non-accidental injury, vitamin deficiency, coagulation disorder, allergic reaction, eczema, contact dermatitis, and insect bites.

Pityriasis rosea is the most likely diagnosis given the patient’s history of a herald patch and the appearance of the rash. Tinea corporis is a fungal infection that typically presents with a red, scaly rash with a clear center. Psoriasis is a chronic inflammatory skin condition that is characterized by red, scaly patches of skin. Eczema is a chronic inflammatory skin condition that is often associated with allergies and asthma. Drug eruption is a rash caused by an allergic reaction to a medication.

Lisa’s symptoms are suggestive of lichen sclerosus, which requires treatment with potent topical corticosteroids and regular follow-up due to the increased risk of squamous cell carcinoma. Differential diagnoses include: 1. Lichen sclerosus, 2. Atrophic vaginitis, 3. Vulvar intraepithelial neoplasia, 4. Chronic vulvovaginal candidiasis, 5. Psoriasis, 6. Lichen planus, 7. Intertrigo. The wrong answers either misdiagnose or inadequately manage the risk factors involved.

The most appropriate management is to discontinue the irritant and use topical corticosteroids . The appearance of the rash after starting a new detergent suggests allergic contact dermatitis. Dapsone is used for dermatitis herpetiformis, permethrin is for scabies, a gluten-free diet is for dermatitis herpetiformis, and oral antihistamines may help with itching but do not address the underlying cause. Differential diagnoses include eczema, psoriasis, and urticaria.

For a red-back spider bite with localized symptoms only, the most appropriate treatment is to apply ice to the bite area and provide analgesics for pain management. Antivenom and antibiotics are not typically required unless there are signs of severe envenomation or secondary infection. Differential diagnoses include: red-back spider bite, cellulitis, allergic reaction, local trauma, insect bite, abscess formation, and non-venomous spider bite.

The correct answer is- Explain that geographic tongue is benign and not cancerous. Reassuring the patient about the benign nature of geographic tongue can alleviate his concerns. Differential diagnoses include oral candidiasis, tongue cancer, iron deficiency anemia, herpes simplex infection, vitamin B12 deficiency, allergic reactions, and lichen planus.

Otitis externa is the most likely diagnosis given the patient’s history of surfing, ear canal debris, and pain with earlobe movement. The symptoms are consistent with inflammation and infection of the external ear canal.

Correct answer is – MRI of the brain and internal auditory canal. This investigation can help rule out acoustic neuroma and other central causes of sudden sensorineural hearing loss. Tympanometry and pure tone audiometry assess hearing loss but do not identify the underlying cause. A CT scan is less sensitive for soft tissue lesions like neuromas. Blood glucose level is irrelevant to the immediate investigation of hearing loss. Differential diagnoses include acoustic neuroma, labyrinthitis, sudden idiopathic sensorineural hearing loss, vascular events, and multiple sclerosis.

The correct answer is- Acute pancreatitis. The combination of epigastric pain radiating to the back and elevated lipase levels is indicative of acute pancreatitis, commonly associated with alcohol use. Differential diagnoses include peptic ulcer disease, gallstones, gastritis, hepatitis, myocardial infarction, esophageal spasm, and biliary colic.

The correct answer is- Refer urgently to a hematologist. The presence of anemia, lymphadenopathy, and weight loss warrants urgent referral for further investigation. Differential diagnoses include infectious mononucleosis, iron deficiency anemia, depression, substance abuse, chronic fatigue syndrome, tuberculosis, and non-Hodgkin’s lymphoma.

Correct answer: Susan’s presentation is highly suggestive of a possible ectopic pregnancy, and a serum beta-hCG test is crucial for diagnosis. Differential diagnoses include: 1) Ectopic pregnancy, 2) Acute appendicitis, 3) Ovarian torsion, 4) Ruptured ovarian cyst, 5) Pelvic inflammatory disease, 6) Endometriosis, 7) Urinary tract infection. B – An ultrasound is important but follows confirmation of pregnancy. C – Antibiotics are not indicated without confirmation of PID. D – Laparotomy is invasive and follows confirmation. E – NSAIDs do not address the potential ectopic pregnancy.

The Red Book promotes evidence-based medicine, ensuring that recommended interventions offer clear benefits for specific populations. Screening tests without proven benefit are not recommended to avoid potential risks.

Methotrexate, in combination with folic acid, is used to manage rheumatoid arthritis by modifying the disease course and preventing joint damage. Folic acid is given to reduce the side effects of methotrexate, such as gastrointestinal issues and mucositis. Differential diagnoses for consideration include rheumatoid arthritis, SLE, osteoarthritis, gout, psoriatic arthritis, viral arthritis, and spondyloarthritis. Methotrexate is effective in managing rheumatoid arthritis and modifying the disease course, while folic acid helps mitigate its side effects.

The correct answer is- Seronegative rheumatoid arthritis. A positive anti-CCP with a negative rheumatoid factor suggests seronegative rheumatoid arthritis, which can still be aggressive and requires treatment. Osteoarthritis, SLE, gout, and fibromyalgia have different diagnostic profiles. Differential diagnoses include seronegative rheumatoid arthritis, osteoarthritis, SLE, psoriatic arthritis, gout, viral arthritis, and spondyloarthritis.

Topical estrogen therapy is the most appropriate initial management for postmenopausal women experiencing dyspareunia due to vaginal atrophy. Referral to a pelvic pain specialist may be needed if symptoms persist. Cognitive-behavioral therapy is more appropriate for psychological factors. Vaginal dilators and pelvic floor physical therapy may be considered if topical estrogen therapy fails, but are not first-line treatments. Differential diagnoses include vaginal atrophy, vulvovaginal atrophy, lichen planus, endometriosis, pelvic inflammatory disease, vestibulodynia, and vulvodynia.

Polycystic ovary syndrome (PCOS) is the most likely cause given Maria’s irregular menstrual cycles and hirsutism. Tubal obstruction is less likely with normal semen analysis. Hyperprolactinemia usually presents with additional symptoms. Endometriosis often has different symptoms. Uterine fibroids would present with other symptoms. Differential diagnoses include PCOS, hypothyroidism, ovarian insufficiency, early menopause, chronic anovulation, adrenal hyperplasia, and stress-related infertility.

Correct answer: Mia’s symptoms and recent travel history suggest a possible tick-borne disease, such as Lyme disease. Serological tests can help confirm the diagnosis. Differential diagnoses include: 1) Lyme disease, 2) Rocky Mountain spotted fever, 3) Viral exanthem, 4) Juvenile idiopathic arthritis, 5) Rheumatic fever, 6) Parvovirus infection, 7) Systemic lupus erythematosus. A – Antihistamines are not indicated for suspected tick-borne disease. B – Antibiotics may be needed but should follow confirmation of diagnosis. D – Supportive care is important but does not address the underlying cause. E – Steroids may be used in certain conditions but not as an initial step without diagnosis.

High altitude pulmonary edema (HAPE) . is the most likely diagnosis due to Ms. Carter’s recent travel to high altitude, increasing shortness of breath, and decreased breath sounds. This condition typically presents with symptoms following rapid ascent to high altitudes and is characterized by tachycardia and decreased breath sounds. Other options like pneumonia, asthma, and COPD would present differently and are less consistent with the history of recent travel.

The most appropriate management is urgent laparoscopy due to the presence of circulatory collapse and severe pain, indicating a possible ruptured ectopic pregnancy. Differential diagnoses include: 1. Ectopic pregnancy, 2. Ovarian torsion, 3. Acute appendicitis, 4. PID, 5. Ovarian cyst rupture, 6. Endometriosis, 7. Gastrointestinal perforation.

The correct answer is- Sarcoidosis is compatible with a long and active life. Most patients with sarcoidosis have a good prognosis and can lead normal lives, although some may require intermittent treatment. Differential diagnoses include tuberculosis, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, granulomatosis with polyangiitis, systemic lupus erythematosus, thyroid cancer, and metastatic breast cancer.

The appropriate management step for retinal detachment is immediate referral for sealing of retinal tears. The symptoms suggest retinal detachment, which requires urgent surgical intervention. Differential diagnoses include vitreous haemorrhage, central retinal artery occlusion, and central retinal vein thrombosis.

The most appropriate initial treatment for a confirmed DVT is to start low molecular weight heparin (LMWH), such as enoxaparin, to prevent further clot formation and embolization. Differential diagnoses include cellulitis, Baker’s cyst, muscle strain, venous insufficiency, lymphedema, and superficial thrombophlebitis. Oral aspirin is not effective for treating DVT. Thrombolytic therapy is reserved for massive DVT with severe symptoms. Warfarin is typically started after LMWH, not immediately. Compression stockings are supportive but not a primary treatment.

The most appropriate management involves prescribing analgesics and encouraging deep breathing to prevent complications such as pneumonia. Differential diagnoses include: rib fracture, pneumothorax, lung contusion, splenic injury, hepatic injury, kidney trauma, and intercostal muscle strain. Elastic rib belts or surgical interventions are less supported by evidence or unnecessary for simple fractures.

The correct answer is- Abstain from sexual activity during outbreaks. Avoiding sexual contact during active outbreaks reduces the risk of transmission to partners. Differential diagnoses include syphilis, gonorrhea, chlamydia, balanitis, chancroid, fixed drug eruption, and Behçet’s disease.

Referral for adenotonsillectomy is the most appropriate management for a child with obstructive sleep apnea due to enlarged tonsils. Differential diagnoses include: 1) Allergic rhinitis 2) Asthma 3) Attention deficit hyperactivity disorder 4) Gastroesophageal reflux disease 5) Obesity 6) Craniofacial abnormalities 7) Neuromuscular disorders

The correct answer is- Chromosomal abnormalities. Early miscarriages are often due to isolated chromosomal abnormalities, which are usually not recurrent. Differential diagnoses include uterine abnormalities, hormonal imbalance, infection, immunological disorders, cervical incompetence, lifestyle factors, and thrombophilia.

Obesity is a major risk factor for a number of chronic diseases, including type 2 diabetes, heart disease, stroke, and sleep apnea. It is important to address obesity early to reduce the risk of these complications.

The correct answer is- Non-maleficence (do no harm). The GP must ensure that any action taken does not intentionally harm the patient, such as administering a medication with the intent to hasten death. Differential diagnoses include ethical dilemmas in palliative care, end-of-life care issues, anxiety in family members, misunderstanding of medical processes, potential elder abuse, depression in family members, and caregiver fatigue.

The correct answer is- Polymyalgia rheumatica (PMR). The age of the patient, sudden onset of stiffness, and prolonged morning stiffness are characteristic of PMR. Other conditions like rheumatoid arthritis and fibromyalgia have different clinical presentations. Differential diagnoses include rheumatoid arthritis, osteoarthritis, fibromyalgia, depression, multiple myeloma, temporal arteritis, and hypothyroidism.

Increasing perindopril to 10mg daily, optimizing diabetes management, starting statin therapy, and referring to a nephrologist is the most appropriate next step. Differential diagnoses include diabetic nephropathy, hypertensive nephrosclerosis, IgA nephropathy, and renovascular disease. This comprehensive approach addresses multiple aspects of CKD management in a high-risk patient with Stage 3b CKD. A) Increasing perindopril alone is insufficient. B) Adding amlodipine doesn’t address proteinuria or other risk factors. D) Spironolactone may worsen hyperkalemia risk. E) Switching to valsartan offers no clear benefit over perindopril.

Blood glucose level, urine analysis, and HbA1c are necessary to confirm the diagnosis of type 1 diabetes mellitus. Thyroid function tests can help to rule out hyperthyroidism as a possible cause of the patient’s symptoms.

The correct answer is- Corneal light reflex test. The corneal light reflex test helps assess eye alignment by observing the reflection of light on the corneas. Differential diagnoses include congenital esotropia, intermittent exotropia, pseudostrabismus, refractive error, retinoblastoma, cataract, and neurological disorder.

The likely diagnosis is dry macular degeneration . It presents with gradual loss of central vision and distortion of vision. Differential diagnoses include wet macular degeneration, retinal detachment, central retinal artery occlusion, and vitreous haemorrhage.

The correct answer is- Malabsorption due to Coeliac disease. Coeliac disease can cause malabsorption, leading to iron deficiency anemia and fatigue. Noncompliance with a gluten-free diet could contribute, but malabsorption is the direct cause. Differential diagnoses include iron deficiency anemia, vitamin B12 deficiency, folate deficiency, inflammatory bowel disease, small intestinal bacterial overgrowth, chronic gastrointestinal bleeding, and thyroid dysfunction.

The patient’s presentation, including persistent lymphadenopathy and elevated lymphocytes, with a blood film showing sparse cytoplasm, is indicative of Chronic Lymphocytic Leukaemia (CLL). This condition is common in older adults and often presents with lymphadenopathy and elevated lymphocytes. Acute lymphoblastic leukaemia and other conditions like infectious mononucleosis or myeloma have different clinical and laboratory features.

Correct answer is to refer to a hepatologist for further assessment and potential antiviral therapy. Differential diagnoses include autoimmune hepatitis, alcoholic liver disease, non-alcoholic fatty liver disease, hemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, and drug-induced liver injury. Vaccination is inappropriate in an already infected patient; antivirals might be necessary but require specialist input; lifestyle modifications alone are insufficient; liver biopsy may be considered after hepatology consultation.

Endoscopy is useful for assessing oesophageal causes of chest pain, such as GERD. An exercise stress test and transthoracic echocardiography are more relevant for cardiac causes. Serum enzymes and chest X-ray do not directly assess oesophageal conditions. Endoscopy allows direct visualization of the esophagus and can identify inflammation or structural abnormalities.

Transoesophageal echocardiography (TOE) is the most sensitive investigation for aortic dissection. A chest X-ray and transthoracic echocardiography are useful but less sensitive. An exercise stress test and serum enzymes are not relevant for diagnosing aortic dissection. TOE provides detailed images of the aorta and can quickly confirm the presence of a dissection.

An exercise stress test is most appropriate to define the cardiac origin of chest pain during exercise. A chest X-ray and transthoracic echocardiography are useful but do not specifically assess exercise-induced ischemia. Blood glucose and haemoglobin tests are not directly related to diagnosing cardiac chest pain. The exercise stress test evaluates for myocardial ischemia by assessing ECG changes during physical exertion.

Retained tampons can cause persistent discharge and irritation. Removing the tampon and managing any resultant infection or irritation is crucial. Differential diagnoses include: 1. Retained foreign objects (e.g., tampons), 2. Bacterial vaginosis, 3. Candida albicans, 4. Atrophic vaginitis, 5. Contact dermatitis, 6. Diabetes-related infections, 7. Vulvar malignancies.

The most appropriate action for the GP in this situation is to repeat the blood test to confirm the results. The eGFR calculation may be inaccurate due to factors such as ethnicity and age. It is important to confirm the diagnosis of chronic kidney disease before initiating any treatment or referral. Explaining the results to the patient and monitoring kidney function are important, but they should be done after confirming the diagnosis. Starting treatment with antihypertensive medication is not necessary at this stage, as the patient’s blood pressure is already well controlled.

Patient education is crucial in the management of BPH. The patient should be informed about the importance of regular follow-up appointments, lifestyle modifications to improve symptoms, the potential complications of BPH, and the importance of seeking medical attention for worsening symptoms.

Rheumatic fever is associated with a history of untreated sore throats, fever, joint pain, and rash. Differential diagnoses include systemic lupus erythematosus, infective endocarditis, viral exanthema, reactive arthritis, rheumatoid arthritis, and Kawasaki disease. A is incorrect as systemic lupus erythematosus would have additional systemic involvement. B is incorrect as infective endocarditis would present with a history of intravenous drug use or prosthetic valves. C is incorrect as viral exanthema would not cause joint pain. E is incorrect as reactive arthritis follows gastrointestinal or genitourinary infections.

Diabetic Nephropathy (DN)

Diabetic nephropathy (DN) is exceedingly common in patients with both type 1 and type 2 diabetes mellitus and is characterized by persistent albuminuria (>30 mg/g) and/or decreased glomerular filtration rate (GFR) (e.g., elevated creatinine). DN is typically slowly progressive for years before clinical signs occur.

The diagnosis is usually made clinically, with renal biopsy reserved for patients with an unclear presentation. In the absence of signs suggesting another etiology (e.g., casts in the urine, rapid progression of renal dysfunction), the diagnosis can be presumed in patients who have persistent albuminuria and/or decreased GFR and either of the following:

• Prolonged history of diabetes:

  • Type 1 diabetes is typically clinically obvious at onset; therefore, DN may be assumed in those with a disease duration of ≥5 years.
  • In contrast, type 2 diabetes is often asymptomatic, so patients may have this disorder for years before diagnosis, making the duration of the disease difficult to calculate.

• Proliferative Diabetic Retinopathy (PDR):

  • Both PDR (i.e., retinal neovascularization) and DN are chronic microvascular complications of diabetes due to persistent hyperglycemia, so the presence of PDR correlates with diabetic kidney disease.
  • Therefore, patients may be diagnosed with DN if there is concomitant PDR, regardless of the length of time since diagnosis.

Differential Diagnoses

• (Choice A) Renal Size Discrepancy

  • Seen in patients with unilateral chronic kidney disease (e.g., renal artery stenosis, ureteral obstruction).
  • With prolonged DN, both kidneys would likely be shrunken and atrophic.

• (Choice B) Left Ventricular Hypertrophy (LVH)

  • Correlates with chronic, uncontrolled hypertension.
  • Although uncontrolled hypertension may be seen in patients with chronic kidney disease, it is not specific for DN.

• (Choice C) Microscopic Hematuria

  • Although microscopic hematuria may occur with DN, it is nonspecific and may be seen in a variety of diseases (e.g., malignancy, nephritic syndromes).

• (Choice D) Rapidly Progressive Renal Dysfunction

  • DN usually develops over a prolonged period (years).
  • Rapidly progressive renal dysfunction suggests an alternate diagnosis (e.g., lupus nephritis) and further workup.
  • Renal biopsy may be indicated.

Learning Objective

Diabetic nephropathy (DN) is characterized by persistent albuminuria (>30 mg/g) and/or decreased glomerular filtration rate. In the absence of signs suggestive of another etiology, the diagnosis can be presumed in patients with renal dysfunction and either:

• A prolonged history of diabetes (≥5 years for type 1 diabetes)
• Proliferative diabetic retinopathy, which correlates with the presence of DN

Type 2 Diabetes in Adolescents and Young Adults

This patient with a new diagnosis of diabetes mellitus (elevated hemoglobin A1c level, symptomatic hyperglycemia [e.g., polydipsia], vulvovaginal candidiasis) likely has type 2 diabetes. Although type 2 diabetes is more common in older individuals, the incidence in adolescents and young adults is increasing in association with a rise in childhood obesity (e.g., BMI ≥95th percentile for age).

Excess adiposity contributes to insulin resistance, which is further aggravated by rising growth hormone levels at puberty. A positive family history of diabetes increases the risk; the incidence is also higher in certain racial and ethnic groups (e.g., Black and Native American patients).

Associated Features of Insulin Resistance

• Central (visceral) obesity
• Elevated blood pressure
• Lipid abnormalities (e.g., hypertriglyceridemia, decreased HDL levels)
• Acanthosis nigricans: Velvety, hyperpigmented patches in intertriginous areas (e.g., neck, axillae)

Differential Diagnoses

• (Choice A) Growth Hormone-Secreting Pituitary Adenoma

  • Can cause diabetes mellitus
  • Bitemporal hemianopia may occur due to optic chiasm compression
  • However, patients typically display gigantism or acromegaly rather than obesity

• (Choice B) Chronic Pancreatitis

  • Can lead to exocrine pancreatic insufficiency → steatorrhea
  • Loss of beta cells can cause secondary diabetes
  • However, this is much more common at age >30 and is typically associated with:
    • Chronic abdominal pain
    • Nausea
    • Weight loss

• (Choice D) Glucokinase Gene Mutation (MODY – Maturity-Onset Diabetes of the Young)

  • Characterized by decreased insulin secretion at any glucose level
  • Patients are typically not obese
  • Hyperglycemia is usually mild (<140 mg/dL)

• (Choice E) Autoimmune Type 1 Diabetes

  • Pancreatic autoantibodies cause loss of islet cells
  • Leads to absolute insulin deficiency (vs. relative deficiency in type 2 diabetes)
  • Increased ketone production can lead to diabetic ketoacidosis (DKA)
  • Typical features include:
    • Rapid-onset hyperglycemia
    • Ketonuria (absent in this patient)
    • Hyperventilation
    • Abdominal pain

Learning Objective

The incidence of type 2 diabetes in adolescents and young adults is increasing due to rising childhood obesity. Excess adiposity contributes to insulin resistance, which is further aggravated by pubertal growth hormone levels. Other findings associated with insulin resistance include acanthosis nigricans, central obesity, hypertension, and lipid abnormalities.

Hyperprolactinemia Due to Antipsychotic Use

This patient’s history of paranoia, social isolation, and disorganized behavior suggests psychosis, likely being treated with an antipsychotic medication. Antipsychotic drugs block dopamine, and since dopamine inhibits prolactin release, dopamine blockade in the tuberoinfundibular pathway can lead to hyperprolactinemia. This can result in gynecomastia, galactorrhea, menstrual dysfunction, and decreased libido.

Risperidone, a commonly used second-generation antipsychotic (SGA), is known for its high frequency of prolactin elevation and is the most likely cause of this patient’s symptoms.

Differential Diagnoses

• (Choice A) Aripiprazole

  • Functions as a dopamine D2 receptor antagonist and partial agonist
  • Due to its partial agonism, it is less likely to cause hyperprolactinemia

• (Choice B) Galactocele

  • A benign milk collection in lactating women, usually due to a blocked duct
  • This patient’s pregnancy test is negative, and there is no indication of breastfeeding

• (Choice C) Hypothyroidism

  • Can predispose to hyperprolactinemia, but typically presents with:
    • Lethargy
    • Dry skin
    • Cold intolerance
  • This patient has none of these symptoms, and her TSH level is normal

• (Choice D) Polycystic Ovary Syndrome (PCOS)

  • Associated with elevated androgens, leading to:
    • Acne
    • Hirsutism
    • Menstrual irregularities
  • Can occasionally cause elevated prolactin levels, but this patient lacks symptoms of hyperandrogenism

• (Choice E) Prolactinoma

  • A benign pituitary tumor causing:
    • Headaches
    • Visual disturbances (due to mass effect)
  • Can lead to extremely high prolactin levels (>200 ng/ml)
  • In contrast, medication-induced hyperprolactinemia typically results in prolactin levels between 25-100 ng/ml

• (Choice G) Valproate

  • An anticonvulsant used for:
    • Bipolar disorder
    • Seizures
  • Does not cause galactorrhea, but is associated with:
    • Blood dyscrasias
    • Liver toxicity

Learning Objective

Antipsychotic medications can cause hyperprolactinemia due to dopamine blockade in the tuberoinfundibular pathway. Risperidone has a particularly high risk of prolactin elevation. In contrast, prolactinomas typically produce very high prolactin levels (>200 ng/ml), whereas antipsychotic-induced hyperprolactinemia generally results in levels between 25-100 ng/ml.

Short Stature and Constitutional Growth Delay

This patient has short stature, defined as height below the 2nd percentile for sex and age. The most common causes of short stature are constitutional growth delay and familial short stature.

Constitutional Growth Delay

• Recognized by a delayed bone age and a normal linear growth velocity starting around age 3
• Affected children typically have a normal birth weight and height but exhibit slowed linear growth velocity between 6 months and 3 years, leading to a height below the 2nd percentile
• After age 3, growth resumes at a normal rate (ie, normal growth velocity), with the growth curve remaining below but parallel to the lowest percentile line
• Delayed puberty, including late adolescent growth spurt
• Bone age (skeletal maturation) is delayed relative to chronological age
• Ultimately, patients experience a normal growth spurt and achieve a normal adult height

Management

• Reassurance and monitoring of linear growth velocity

Differential Diagnoses

• (Choice A) Celiac Disease

  • Can cause short stature and delayed bone age
  • Typically presents with weight loss and gastrointestinal symptoms (eg, diarrhea, abdominal distension)
  • This patient has appropriate weight gain and no gastrointestinal symptoms

• (Choice C) Familial Short Stature

  • Bone age is normal and matches chronologic age
  • Puberty is not delayed
  • Patients have a normal linear growth velocity (stable percentile), similar to constitutional growth delay
  • One or both parents also have short stature (not the case in this patient)
  • Final adult height remains low

• (Choice D) Growth Hormone Deficiency

  • Causes short stature, delayed puberty, and delayed bone age
  • Slowed linear growth velocity, with height percentiles crossing 2 major percentiles downward (eg, from 50th to 25th)
  • This patient’s height percentile is stable, suggesting normal linear growth velocity

• (Choice E) Hypogonadism (Testosterone Deficiency)

  • Can be congenital (eg, Klinefelter syndrome) or acquired (eg, testicular trauma or infection)
  • Delayed puberty, but normal bone age
  • Most patients have gynecomastia, which is not present in this case
  • Often associated with increased LH, FSH, and estradiol due to lack of testosterone’s negative feedback

• (Choice F) Hypothyroidism

  • Causes declining linear growth velocity and pubertal delay
  • This patient’s linear growth velocity is normal
  • No symptoms of hypothyroidism (eg, fatigue, constipation, cold intolerance)

Learning Objective

Constitutional growth delay is characterized by short stature (height below the 2nd percentile), delayed bone age, and a normal linear growth velocity after age 3. Delayed puberty is common, but patients eventually experience a normal growth spurt and achieve a normal adult height.

Nutritional Rickets

Nutritional rickets is most commonly caused by vitamin D deficiency, which is essential for calcium metabolism and skeletal growth. Risk factors include limited sun exposure and increased skin pigmentation. Exclusively breastfed infants who do not receive vitamin D supplementation, as in this case, are at high risk because breast milk alone contains inadequate vitamin D.

Deficiency of vitamin D and calcium results in poor bone mineralization and growth plate cartilage accumulation. Clinical features include:

• Craniotabes (skull bones that depress with pressure), as seen in this infant
• Widened wrists due to growth plate enlargement
• Radial/ulnar bowing
• Delayed fontanel closure
• Lower extremity bowing (genu varum) once the child begins weight-bearing

Diagnosis & Imaging

X-ray of rapidly growing skeletal areas (eg, wrists, knees) is helpful for diagnosis. Classic findings include:

• Metaphyseal widening with cupping and fraying (white arrow), as seen here
• Costochondral joint widening

Treatment

Treatment involves vitamin D and calcium supplementation.

Differential Diagnoses

• (Choice A) Systemic Juvenile Idiopathic Arthritis (JIA)

  • Autoimmune inflammatory disorder
  • Presents with fever, arthritis, and rash (none of which are present here)
  • X-rays show soft tissue swelling and loss of joint space, not metaphyseal changes

• (Choice B) Hurler Syndrome

  • Autosomal recessive lysosomal storage disease
  • Characterized by dysostosis multiplex (shortened, thickened long bones)
  • Other features include coarse facial features (wide nasal bridge, flat midface), developmental delay, and frequent infections, none of which are seen here

• (Choice C) HIV

  • Can be transmitted via breast milk
  • Presents with hepatosplenomegaly, lymphadenopathy, and failure to thrive, rather than bony abnormalities
  • Milk banks screen donors for infectious diseases and pasteurize milk to destroy pathogens, including HIV

• (Choice D) Congenital Syphilis

  • Often asymptomatic at birth, but may cause skeletal abnormalities
  • Can present with craniotabes and osseous destruction of long bones, but not metaphyseal cupping and fraying
  • Other findings (eg, hepatosplenomegaly, rash, lymphadenopathy) are absent in this case

• (Choice E) Nonaccidental Trauma

  • Can present with localized swelling without reported trauma
  • New and/or old fractures would be expected on x-ray
  • Craniotabes would not be present in nonaccidental trauma cases

Learning Objective

Nutritional rickets classically occurs in exclusively breastfed infants who do not receive vitamin D supplementation. It presents with craniotabes (soft skull bones) and forearm deformities (widened wrists, radial/ulnar bowing). Lower extremity bowing develops once the child starts weight-bearing.