The mother did not receive any Anti-D injections in her previous pregnancy. The stem is trying to tell you that she was immunized during her last pregnancy when delivered a Rhesus (+ve) baby. This woman now has antibodies against fetal RBC. They attack fetal red blood cells causing a bilirubin build up leading to jaundice. Other common causes of jaundice which present within 24 hours of birth are ABO incompatibility, G6PD, and sepsis. However, the stem does not provide any information that would point you to pick any of them.

Phaeochromocytoma is a rare catecholamine secreting tumour.

Rule of 10 -

• Bilateral in 10%

• Malignant in 10%

• Extra-adrenal in 10% (most common site = organ of Zuckerkandl, adjacent to the bifurcation of the aorta)

• 10% are familial and may be associated with MEN type II, neurofibromatosis, and von Hippel-Lindau syndrome

• 10% not associated with hypertension Features are typically episodic. 

• Hypertension (around 90% of cases and may be sustained)

• Headaches

• Palpitations

• Profuse sweating

• Anxiety

• Tremor

Mnemonic : PHaeochromocytoma P - Palpitations H- Headaches PH -PH lushings (flushing)

Tests - • 24-hour urinary collection of metanephrines (sensitivity 97%)

Note: this has replaced a 24-hour urinary collection of catecholamines (sensitivity 86%)

Management : Surgical resection of the tumour is the treatment of choice and usually results in a cure for hypertension.

However, the patient must first be stabilized with medical management:

• Alpha-blocker (e.g. phenoxybenzamine) • Beta-blocker (e.g. propranolol) Note: Alpha blocker must be given before a beta blocker. The reason behind medical management with alpha-blockers and beta-blockers is it is required to control blood pressure to prevent intraoperative hypertensive crises. Alpha blockade with phenoxybenzamine is started at least 7 to 10 days before operation to allow for expansion of blood volume. Only once this is achieved is the beta-blockade considered. If beta blockade is started too soon, unopposed alpha stimulation can precipitate a hypertensive crisis.

As a general rule, platelet deficiency causes petechial haemorrhages and ecchymoses (bruising) whilst clotting factor deficiency produces haematomas and haemarthroses. This question gives a mixed picture where there are descriptions of both platelet deficiency (petechial haemorrhages seen on his buttocks) and factor deficiency (bleeding/swelling at his knee). However, the prolonged aPTT supports the diagnosis of haemophilia thus that is the answer. 

Amyotrophic lateral sclerosis (ALS) is the most common form of motor neuron disease in addition to multiple sclerosis (MS). Know the distinction between both for exam as they will commonly appear as either a question or an option. MS usually presents in episodes intermittently and affects different anatomic locations. Myasthenia gravis would present with weakness and fatigue along with a positive autoimmune panel. Guillain-Barre syndrome would usually give a clue to a prior infection. Polymyositis would affect the lower limbs first with fatigue.

Tubo-ovarian abscess is an advanced complication of acute salpingitis, known clinically  as pelvic inflammatory disease. Ultrasonography should be done in very ill patients in  whom tubo-ovarian abscess is suspected. A high vaginal swab or endocervical swab can take days to return with results. As this is an A&E case, an ultrasound would be more appropriate as this would lead to a diagnosis.

Painless vaginal bleeding is consistent with placenta praevia. Placental abruption is associated with abdominal pain. Placenta accreta and vasa praevia are less common than placenta praevia. There is no indication that she is in labour.

The combination of deranged LFTs combined with secondary amenorrhoea in a young female strongly suggests autoimmune hepatitis. In autoimmune hepatitis, serum aminotransferases: aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are usually elevated at initial presentation. Serum alkaline phosphatase is normal or only mildly raised. A more than two-fold elevation suggests an alternative or additional diagnosis. Occasionally, the stem would include a form of another autoimmune disease such as Addison’s disease, vitiligo, or an autoimmune thyroid disorder as this may be present with autoimmune hepatitis. Autoimmune hepatitis (AIH) is a chronic disease of unknown cause, characterised by continuing hepatocellular inflammation and necrosis, which tends to progress to cirrhosis. • Predominantly affects young or middle-aged women • Up to 40% present with acute hepatitis and signs of autoimmune disease, eg fever, malaise, urticarial rash, polyarthritis, pleurisy, pulmonary infiltration, or glomerulonephritis. The reminder present with gradual jaundice or are asymptomatic and diagnosed incidentally with signs of chronic liver disease. Amenorrhoea is common and the disease tends to attenuate during pregnancy. Investigations: The diagnosis rests on a combination of compatible biochemical, immunological and histological features together with the exclusion of other liver diseases. Associated diseases, Concurrent autoimmune disorders occur in approximately 40% of patients, particularly autoimmune thyroid disorders.

Salpingitis, endometriosis, ovarian torsions, and ovarian tumours are not associated with amenorrhoea. Patients' pelvic pain and vaginal bleeding with peritonism and cervical excitation point towards ectopic pregnancy.

This is a very straightforward question but it does test your knowledge of lung function testing thoroughly. The pulmonary indices indicate a restrictive lung disease. The only choice that is a restrictive lung disease is pulmonary fibrosis. Asthma, bronchiectasis, pulmonary oedema, and chronic obstructive pulmonary disease are all obstructive lung diseases.

Preoperative antibiotics reduce the risk of surgical site infections, especially in high-risk procedures like impacted tooth extraction.

The best answer here is coeliac disease. Whilst coeliac disease indeed causes malabsorption which accounts for intermittent diarrhoea and abdominal bloating, the more specific answer is still Coeliac disease since there is a history of wheat in the diet. Eggs do not exacerbate coeliac disease as it is not gluten however her meals which contain wheat is likely the cause of her malabsorption symptoms. 

Spontaneous pneumothorax is common in Marfan’s syndrome. The other signs and symptoms point toward Marfan’s syndrome as well.

This patient most likely has a nephrotic syndrome : • Proteinuria • Hypoalbuminaemia • Oedema The most likely diagnosis is minimal change disease. The peak incidence is around 3-4 years of age. However, it can occur in older children. It is steroid-responsive in the majority of cases, however a small number of patients require cyclophosphamide. The diagnosis of minimal change disease can be made on clinical and biochemical grounds alone. However, a renal biopsy can be performed to demonstrate podocyte fusion and deformity on electron microscopy. IgA glomerulonephritis causes nephritis and typically occurs a few days after an upper respiratory tract infection.

Heinz bodies are pathognomic for G6PD deficiency. In exam, if you see a question that has Heinz bodies on a blood film, you can almost be certain that this is G6PD deficiency. Haemolysis in this case was elicited by treatment of malaria. Usually primaquine is the culprit. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is X-linked and clinically important cause of oxidant haemolysis.

Fluctuant swelling of the scrotum which feels like worms are suggestive of varicocele.

The likely diagnosis here is ovarian torsion. Although ovarian torsion cannot be diagnosed clinically as it is often diagnosed in theatre during a laparoscopy, the examiners want you to consider ovarian torsion as part of your differential diagnosis as it is one of the important gynaecologic emergencies. It is quite rare and only accounts for about 3% of gynaecologic emergencies however it is important to consider it especially given that this patient has a tender mobile mass at the right iliac fossa. In clinical practice, appendicitis would also be part of your differential. If there was a history of an ovarian mass or if an ultrasound pelvis was done which found an ovarian mass, then the surgeons would refer her to the gynaecology team to rule out an ovarian torsion. Ovarian torsion presents with sudden onset of sharp, unilateral lower abdominal pain often with nausea and vomiting. In the reproductive years, regular growth of large corpus luteal cysts is a risk factor for rotation. Any enlargement of the ovary is a risk factor for ovarian torsion. The definitive diagnosis is often made in the theatre as ovarian torsion is difficult to diagnose accurately and an operation is often performed before the diagnosis is made.

The given case is a classic picture of acute epiglottitis. The clincher here is drooling of saliva. If you find any questions with a child with drooling saliva, this is likely acute epiglottitis. Call an experienced anaesthetist to intubate before obstruction occurs.

Hypokalaemia and non-bilious vomiting should direct you toward pyloric stenosis as a diagnosis. It is unlikely to be duodenal atresia as the newborn presents with bilious vomiting with every feed. In this question, the scenario was one of non-bilious vomiting. Malrotation is manifested by bilious vomiting, crampy abdominal pain, abdominal distention, and the passage of blood and mucus in their stools. Again in this scenario, non-bilious vomiting was given. Pyloric stenosis :- Projectile non-bilious vomiting. - Age group: 3-8 weeks - Olive-sized abdominal mass - The child will feel hungry and want to feed despite constant vomiting Diagnosis: - Abdominal ultrasound Treatment: - Metabolic alkalosis Correct electrolyte imbalance + hydration, then referral to paediatric surgery (pyloromyotomy) + nasogastric tube.

Chronic pancreatitis often presents with abdominal pain. Classically, the pain is located at the epigastrium and radiates to the back. The pain is worse after eating leading to a dislike of eating with consequent weight loss. The second most predominant feature is malabsorption which is represented here by steatorrhoea. Malabsorption again contributes to weight loss. Alcohol is one of the significant risk factors for chronic pancreatitis but it is not a good hint to pick chronic pancreatitis as the answer based on an alcohol history as alcohol also contributes to acute pancreatitis, gastro-oesophageal reflux, oesophagitis, and indirectly to pancreatic cancer. One might consider “Carcinoma of the head of the pancreas” as the answer given the similar symptoms of weight loss, epigastric pain, and history of alcohol. In reality, it isdifficult to differentiate the two hence the importance of imaging modalities such as ultrasounds and CT scans. In chronic pancreatitis, plain abdominal films of the pancreas can show diffuse calcifications which indicate significant damage to the pancreas. X-rays of the abdomen are not one of the main imaging modalities of the pancreas, and it is usually done for other reasons such as to exclude bowel perforation in A&E. Again to stress that ultrasound and CT scans would be better imaging modalities for pancreatic diseases.

In exam, whenever you see the term “bilateral hilar lymphadenopathy” with a lesion on the shin, you should be thinking of Sarcoidosis. The lesion on the shin is erythema nodosum which are blue or red lesions and are seen in people suffering from sarcoidosis. The syndrome here is Lofgren syndrome which includes erythema nodosum, arthritis, and hilar adenopathy. Lofgren is a distinct sarcoid syndrome. SARCOIDOSIS : Sarcoidosis is a systemic disease of unknown cause, characterized histologically by the presence of nonspecific noncaseating granulomas in the lung and other organs. Presentation : - Up to 50% are asymptomatic (Chest X-ray for another indication reveals the diagnosis from hilar lymphadenopathy) - Involves almost any organ system, but pulmonary involvement is most common (around 90% of symptomatic patients) - Fatigue - Erythema nodosum - Bilateral hilar Lymphadenopathy - Polyarthralgia - Uveitis - Renal Stones • Lofgren syndrome includes : Erythema nodosum, Arthritis, Hilar adenopathy Investigations : • Chest X-ray shows bilateral hilar adenopathy • Elevation in angiotensin-converting enzyme (ACE) can be seen in 60% of patients with sarcoidosis. • Definitive diagnosis is by biopsy of suspected tissue which shows noncaseating granulomas. This can be from the skin, lymph nodes, conjunctiva, or lung. Treatment : Generally in the setting of organ impairment, a trial of steroids may be used.

This is most likely ulcerative colitis. Note that aphthous oral ulcers can be seen in both ulcerative colitis and Crohn’s disease. However, commonly, literature would classify aphthous oral ulcers to be a feature seen only in Crohn’s disease. It is also noted that this patient has blood when he passes stools of which the history points towards ulcerative colitis.  

CROHN’S DISEASE VS ULCERATIVE COLITIS :   It is important to know the differences between ulcerative colitis and Crohn’s disease as it is very commonly asked.

These are some key differences that will help you with your exam:  

Usually non bloody :

* Abdominal mass palpable in right iliac fossa

* Increased goblet cells on histology

* Granulomas seen on histology

* Weight loss is more prominent

* Transmural, skip lesions, cobblestone appearance on endoscopy.  

Ulcerative colitis:

* Bloody diarrhoea is more common

* Abdominal pain in the left lower quadrant

* Decreased goblet cells on histology

* Granulomas are infrequent in histology

* Primary sclerosing cholangitis is more common

* Loss of haustration, drain pipe colon is seen on barium enema.