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Clincher

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PLABABLE

VERSION 1.5

CLINCHER
Oesophageal Stent

Middle aged smoker + metastatic oesophageal


carcinoma in middle third of oesophagus +
severe dysphagia
Currently on palliative care

Mass
compressing
middle third of
oesophagus
causing
dysphagia

How to help with


dysphagia?

Oesophageal stent

PLABABLE
Acoustic Neuroma

30 year old lady with right ear deafness


+ reduced right corneal reflex

Rinne’s test → AC > BC


Weber’s test → Sound lateralises to left ear

Type of hearing loss → Right sensorineural


hearing loss

Have you thought of acoustic neuroma?

Most appropriate investigation?

MRI of cerebellopontine angle

Unilateral sensorineural deafness (CN8) + facial


palsy (CN 7) + absent corneal reflex (CN 5)
→ Acoustic neuroma

PLABABLE
Spironolactone

Middle aged alcoholic man + painless


abdominal distension + spider naevi on
anterior abdominal wall

Vitals → Normal

Investigations
Low albumin
Ascitic tap → Ascitic fluid amylase
around 50% of serum amylase

Appropriate medication to start?

Spironolactone (aldosterone antagonist)

Spironolactone may be used in heart failure,


liver cirrhosis and nephrotic syndrome

PLABABLE
Haematemesis

Old lady with metastatic gastric cancer +


on palliative care + vomited 600 mls of
blood + anxious

Vitals - BP 80/60 mmHg, HR 120 bpm

How would you manage her?

S/C midazolam (aim is to make her


comfortable and reduce her anxiety)
Morphine S/C can also be added to help with
pain

IV fluids or S/C fluids are not appropriate in


this case
PLABABLE
Hypertensive Retinopathy

Old woman with poor vision + poorly


controlled hypertension + headache
Current BP - 160/100 mmHg

Fundoscopy → Dot and blot haemorrhages

Most likely diagnosis?

Hypertensive retinopathy

PLABABLE
Drug Overdose

Old man presented to A&E after consuming 50


paroxetine + 1 bottle of whiskey 12 hours ago

Vitals normal
Investigations:
● ECG normal
● FBC, LFT, UnE normal

Medically fit for discharge

What would you do


before discharging
the patient

Refer to the psychiatry liaison team prior to


discharge

PLABABLE
Xanthelasma

Middle aged man + multiple painless


yellowish plaques on eyelids +
hypertension + hyperlipidemia

Most likely diagnosis?

Xanthelasma

Remember xanthelasma by breaking down the


word

Xanthos → Yellow
Elasma → Beaten metal plates (plaques)
PLABABLE
Hypertension

Man currently on ramipril for hypertension


Poorly controlled hypertension

Past history of pedal oedema with amlodipine

Amlodipine + leg swelling + Already on ACEi →


Use thiazide-like diuretics such as indapamide

PLABABLE
Phobia

25 year old man + develops anxiety


symptoms on boarding a train or going to
a shopping mall

What is the most likely diagnosis?

Agoraphobia

Management - CBT + graded exposure

Do not pick social phobia!

Social phobia is the persistent fear of


performance or social situations

PLABABLE
Cataract

Old lady + gradual impairment of vision


over 6 months + glare and difficulty
driving at night + changing glasses
frequently

On examination - Cornea and pupil are


normal

What is the most likely diagnosis?

Cataract

PLABABLE
Heart Block

65 year old man + 2-3 fainting episodes in


7 days + ECG showing third degree heart
block

What is the definitive treatment for this patient?

Permanent pacemaker

Remember, definitive treatment for type 2


mobitz heart block and complete heart block
is a permanent pacemaker

PLABABLE
Breast Lump

24 year old female + mobile, non-tender,


firm lump in right breast + family history of
maternal breast cancer

What is the most likely diagnosis?

Fibroadenoma

Remember, mobile, non-tender and firm


mass in a young female is most likely a
fibroadenoma.

The history of cancer is given as a


distraction

Fibroadenoma is also called


breast mouse due to it’s
mobility.

Just like a mouse,


fibroadenoma is harmless

PLABABLE
Pneumonia

25 year old man + cough with sputum +


fever + consolidation on chest X-ray +
penicillin allergy

Most likely diagnosis → Pneumonia

Most appropriate treatment?

Doxycycline or clarithromycin

Remember to look out for penicillin allergy in


pneumonia questions!

If patient is also on statins then →


Doxycycline
PLABABLE
Urinary Incontinence

70 year old woman with urinary frequency,


nocturia and urgency

Most likely diagnosis → Urge incontinence

Most appropriate treatment?

Bladder retraining

But, if bladder retraining is not in the options, pick


anticholinergics (antimuscarinic drugs) instead
eg. tolterodine

Remember, pelvic floor exercises are not the


same as bladder retraining

Pelvic floor exercises are used for stress


incontinence

PLABABLE
Breast Pathology

40 year old woman + history of recurrent


breast abscess + thick discharge from
periareolar area

Most likely diagnosis?

Mammary duct fistula

PLABABLE
Halitosis

30 year old man + halitosis + no underlying


cause found + not improving after oral
hygiene measures

Most appropriate treatment?

Antibacterial mouthwash like chlorhexidine

USE

PLABABLE
Fractures In Children

3 year old child brought to AnE with swelling


of arm. X-ray shows spiral fracture of the
humerus with callus formation + another
healed fracture in radius

What is the most likely diagnosis?

Non-accidental injury

Important to rule out NAI in all children with


suspicious injuries + signs of previous healed
injuries

PLABABLE
Post Cholecystectomy

70 year old man + just had successful


cholecystectomy + now has respiratory rate
of 8/min + bilateral miosis + airway has been
maintained

Most likely diagnosis →


Opioid overdose
(postoperative analgesia)

Next step?

Intravenous naloxone

PLABABLE
Foreign Body

10 year old child + unilateral greenish nasal


discharge + history of asthma

What is the most likely diagnosis?

Foreign body

The history of asthma is a distractor


→ Nasal polyps are rare in children and usually
cause watery discharge

PLABABLE
Hypertension

OldP50 year old man on amlodipine for


hypertension + blood pressure is not
controlled now + cannot tolerate ramipril
due to dry cough

Which antihypertensive can be added?

Give either an ARB OR thiazide-like


diuretic
Options for step 2 management of
hypertension include
ACEi/ARBs/thiazide-like diuretics (ACEi
cannot be the answer here as the
patient does not tolerate it)

PLABABLE
Fetal Movements

Woman with 34 weeks pregnancy + history of


recent flu + reduced fetal movements

Next step?

Check fetal viability using handheld


doppler

Once viability is confirmed, perform a CTG

PLABABLE
TURP

65 year old man + underwent


TURP + developed confusion
and seizures

Which electrolyte balance could have


occured?

Hyponatremia

Management → Fluid restriction

PLABABLE
Paracetamol Overdose

30 year old man + ingested 45


tablets of paracetamol 10 hours
ago + haemodynamically stable

What would you do next?

Administer N-acetylcysteine
immediately
This patient meets the following criteria:

● Late presentation: > 8 hours

AND

● Harmful dose: Taking more than 24


pills is likely to surpass 150 mg/kg.
This patient is well over that
benchmark.

PLABABLE
Anorexia Nervosa

21 year old woman + concerned


about her weight + takes
laxatives and diuretics + BMI of
17 kg/m² + BP 88/60 mmHg

What would you do next?

Admit to medical unit

BMI <17.5 kg/m² + evidence of systemic


failure should be admitted immediately

PLABABLE
Shingles

OldP
Pregnant woman came in contact with 50
year old man with shingles

Check her immunity to VZV

VZIG should be given only to those


pregnant females who come in contact with
shingles who do not have immunity to
VZV

If above 20 weeks gestation, aciclovir is


preferred over VZIG due to national
shortage, but VZIG can still be given if
there is no option for antivirals
PLABABLE
Headache

Young female + sudden severe


occipital headache + has a
history of migraine +/- neck
stiffness

What is the next investigation?

CT brain

CT brain is the ideal initial investigation in


suspected cases of SAH or acute stroke

PLABABLE
Hypertension

50 year old man scheduled for


rotator cuff surgery + on
amlodipine, beclomethasone,
lisinopril, atorvastatin + current
BP is 131/78 mmHg

Which medication should be omitted before


surgery?

Lisinopril

ACEi and ARBs should be discontinued on day


of surgery due to risk of hypotension

PLABABLE
Hearing Tests

2 weeks old baby whose mother


is deaf and uses a hearing aid

Which hearing test should be performed?

Otoacoustic emissions (OAE) OR


audiological brainstem responses (ABR)

Want to review when


other hearing tests can
be done?

Be sure to check out


our revision guide. 👆 Click here

PLABABLE
Vomiting

60 year old female + breast


cancer + metastasis to brain +
headache and vomiting

What could be the cause of her symptoms?

Raised intracranial pressure

What is the most appropriate


treatment?

Cyclizine (1st line) OR dexamethasone

PLABABLE
Testicular Cancer

35 year old man with a painless


firm mass in upper part of right
testes

What is the most appropriate initial


investigation?

USG scan of
scrotum

USG scan of scrotum is the first line investigation


for any scrotal lump

Do not pick tumour markers as most appropriate


initial investigation

PLABABLE
Chest Pain

40 year old woman + acute onset


chest pain and shortness of
breath + history of long flight 2
days back + ECG shows sinus
rhythm

What is the most appropriate initial


investigation?

Chest X-ray

Chest X-ray is the initial investigation of choice in


patients with a suspected pulmonary embolism to
rule out other causes such as pneumonia and
pneumothorax

PLABABLE
Prolactinoma

33 year old man + loss of libido +


erectile dysfunction

Prolactin is elevated

MRI suggestive of prolactinoma

What is the most appropriate management?

Cabergoline

Cabergoline is a dopamine agonist

Another option is bromocriptine (2nd line)

PLABABLE
Myocardial Infarction

65 year old man with central


chest pain + dyspnoea +
sweating + nausea
ECG shows left bundle branch block

What is the most likely diagnosis?

Myocardial infarction

Possible ECG changes seen in MI


● ST segment elevation (most tested)
● Pathological Q waves
● Left Bundle Branch Block

PLABABLE
Fracture

70 year old woman + had a fall +


sustained a fracture of the distal
radius + minor displacement of
distal radius + swelling of hand

What is the initial management after


analgesia?

Closed reduction

Followed by

Below elbow POP back slab

PLABABLE
Syphilis

38 year old male +


maculopapular rash on palms
and soles + had penile ulcer 1
week ago which has resolved +
now developed mouth ulcers

What is the most appropriate investigation?

Swab from mouth


ulcer for PCR

Penile ulcer → Darkfield microscopy or PCR


Mouth ulcer → PCR or serology

If both ulcers have healed pick serology

PLABABLE
PCOS

25 year old woman + acne +


irregular periods + raised serum
testosterone

What is the most likely diagnosis

PCOS

What is the most appropriate treatment


for her irregular periods?

Weight loss + COCPs

Metformin does not regulate her periods.

PLABABLE
Bone Pain

65 year old female + metastatic


breast cancer + right hip pain +
currently on oral morphine

What is the most likely cause of


her pain?

Bone metastasis

What is the most appropriate treatment


for her pain?

Radiotherapy

Bisphosphonates + NSAIDs → 2nd line

PLABABLE
Guillain-Barre Syndrome

Middle aged man recovering


from GBS

What is the underlying cause of


this condition?

Demyelination of peripheral nerves

Usually starts as progressive symmetrical


weakness from the lower extremities

PLABABLE
Irregular Menstrual Cycles

24 year old woman + fatigue +


irregular menstrual cycle

TSH - Normal
Prolactin - Normal
FSH - Raised

What is the most likely diagnosis?

Premature ovarian failure

Another raised value of FSH >25 IU/L taken 4


weeks later will be diagnostic of POI

PLABABLE
Penile Ulcers

30 year old man + painful


urination for 3 days + 4 painful
non-indurated ulcers on his
penis

What is the most likely diagnosis?

Herpes simplex virus infection

Multiple painful ulcers +/- dysuria is suggestive


of HSV infection

PLABABLE
Recurrent Infections

7 year old boy who has 3


recurrent throat infections in the
last 1 year + history of cough +
mild inflammation of tonsils with
no exudate + no fever or
palpable lymph nodes

What is the most appropriate


action?

Reassure
Centor score: 0 → Viral tonsillitis
Viral tonsillitis is self limiting and does not
require further treatment or investigation

Less than 7 episodes for 1 year


This patient does not meet the criteria for being
offered tonsillectomy which can be seen here.
PLABABLE
Acne

Young man with past history of acne +


prescribed a drug for it by GP

He has now developed dry lips

What is the most likely drug that was


prescribed to him?

Isotretinoin

Remember that isotretinoin causes dryness!

Dry lips, dry skin, dry eyes and dry nose

PLABABLE
Hyperthyroidism

18 year old woman + palpitations


+ tremors + symptoms of thyroid
eye disease + weight loss +
increased appetite

What is the most likely cause of


her symptoms?

Graves’ Disease

What is the most likely finding that will be


observed on thyroid function tests?

Low TSH, high T4 and high T3

PLABABLE
Panic attacks

21 year old female + requesting


GP to give a fitness note + has
had repeated episodes of panic
attacks + anxious that her job
might be at risk

Besides recommending treatment for panic


attacks what is the most appropriate action?

Refer to occupational therapist

PLABABLE
Menopause

51 year old female with


amenorhoea for 6 months +
flushing + excessive sweating

Which of the following is an appropriate


investigation in her case?
● Thyroid function test
● Oestrogen levels
● FSH

Thyroid function test → To distinguish thyroid


disease symptoms from menopause

FSH testing is not needed for women over the


age of 45 with typical menopausal symptoms.

Oestrogen testing is not recommended for


diagnosing menopause

PLABABLE
BPPV

25 year old woman with sudden


onset of vertigo for 2 weeks +
symptoms worse on lying down
and turning in bed + last for 20
seconds with spontaneous
resolution +no hearing loss

What is the most likely diagnosis?

Benign paroxysmal positional vertigo

What is the most appropriate diagnostic


test and treatment for the patient?

Diagnostic test → Dix-Hallpike manoeuvre

Treatment → Epley’s manoeuvre


PLABABLE
Contraception

31 year old woman + has 2


children + does not want more
children + very heavy menstrual
periods + diagnosed with iron
deficiency anaemia

What is the appropriate contraception to


use?

Levonorgestrel IUS is the ideal


contraception in this case

If LNG IUS is not in the options, pick COCPs

Do not pick tubal ligation as it will not help with


the heavy menstrual periods

PLABABLE
Contraception

25 year old woman + wants


contraception for 6 months +
wants to conceive after 6 months
+ history of dysmenorrhoea and
migraine with aura + Currently
on inhaled salbutamol and
inhaled corticosteroids

What is the appropriate contraception to


use?

Progestogen-only pill

POP is UKMEC 2 in migraine with aura

Copper IUCD is UKMEC 2 in dysmenorrhoea

For short term contraception, POP is more


appropriate here
PLABABLE
Ecstasy

25 year old man + suspected drug ingestion


+ muscle rigidity + elevated temperature +
euphoria

Likely drug ingestion → Ecstasy/MDMA

What is the most appropriate treatment?

Dantrolene

High temperature, muscle rigidity, tachycardia

PLABABLE
Recurrent Falls

66 year old woman with


recurrent falls in the last 3
months + feels dizzy a few
seconds before falling +
currently on a number of
medications

● Apixaban
● Atorvastatin
● Duloxetine
● Denosumab
● Clozapine

Which of the above mentioned medications


could be the cause of her falls?

Duloxetine (SNRI)

Both SSRIs and SNRIs increase the risk of


falling
PLABABLE
Nerve Palsy

35 year old man with double


vision when he looks to the left +
normalises when he closes
either eye

What is the most likely diagnosis?

Left 6th cranial nerve

PLABABLE
Parkinson’s Disease

65 year old man + rigidity of


muscles + tremors + stopped
taking medicines of parkinson’s
disease
O/E → Shuffling gait + bradykinesia

What is the most likely anatomical


structure involved?

Substantia nigra

Low levels of dopamine are a result of the


damage to neurons in substantia nigra

PLABABLE
Nerve Injury

30 year old woman + injured


during car accident in her thigh
and groin + reduced sensation
with mild burning sensation on
lateral side of left thigh

What is the most likely nerve affected?

Lateral femoral cutaneous nerve

This nerve supplies the sensation to the


surface of the lateral thigh

Compression of this nerve causes meralgia


paresthetica which can cause burning,
numbness or tingling of the lateral thigh

PLABABLE
Status Epilepticus

25 year old with generalised


tonic-clonic seizure + seizing for
30 minutes + 2 doses of IV
lorazepam already given + takes
sodium valproate for epilepsy

What is the most likely diagnosis?

Status epilepticus

What is the single most appropriate


management?

IV phenytoin

IV phenytoin and IV phenobarbital can both be


used but, IV phenytoin is preferred

If the patient was already on phenytoin then IV


phenobarbital will be used

PLABABLE
Weakness

44 year old woman with left leg


weakness (power reduced) +
history of controlled epilepsy +
MRI brain and spinal cord are
normal + flexion of left hip
against resistance is not
followed by extension of her
right hip

What is the most likely diagnosis?

Functional weakness

Hoover’s sign is used to identify functional


weakness

In functional weakness, there is no involuntary


extension of hip when flexing the contralateral hip
against resistance

PLABABLE
Nerve Injury

43 year old stabbed in the back


of the neck + open wound on
back of neck with minimal
bleeding + stridor +
asymmetrical rise and fall of
chest on breathing

What is the most likely nerve that is affected?

Phrenic nerve

Phrenic nerve supplies the diaphragm and


damage to this nerve is responsible for the
asymmetrical movements of chest

Stridor is probably due to airway injuries like


tracheal or laryngeal injuries

PLABABLE
Nerve Injury

60 year old man + recently


underwent right submandibular
gland excision for sialolithiasis +
now has decreased tongue
movement + no numbness or
pain in tongue + on protrusion
the tongue deviates to the right

What is the most likely nerve that is affected?

Hypoglossal nerve

Hypoglossal nerve injury can cause


decreased tongue movements and deviation
of tongue

PLABABLE
Breast Cancer

50 year old woman + history of


breast carcinoma and left-sided
mastectomy with ipsilateral
axillary lymph node clearance 2
years back + swelling of left
upper limb for 2 weeks +
tightness of hand + insect bite 4
weeks ago + no rash or fever

What is the most likely reason for swelling?

Lymphoedema

Do not pick angioedema! The time frame does


not match as it would start within a few hours
after insect bite and resolve in 1-3 days

PLABABLE
Skin Lesions

6 year old boy + golden-brown


crust in left perioral area +
started off as thin-walled
vesicles which ruptured + no
fever + drinking and eating well +
mother has been using
antiseptic creams

What is the most likely diagnosis?

Impetigo (uncomplicated)
What is the most appropriate medication to
prescribe?

Topical antibiotics (fusidic acid or mupirocin)

1st line is hydrogen peroxide (antiseptic cream)


which has been already tried

2nd line is topical antibiotics

Oral antibiotics like flucloxacillin are third line or in


systemically unwell patients

PLABABLE
Diabetes

30 year old woman + abdominal


pain and vomiting for 12 hours +
past history of type 1 diabetes
on insulin + capillary glucose is
19 mmol/L and ketones on urine
dipstick is 3+

What is the most likely diagnosis?

Diabetic ketoacidosis
What is the most appropriate/initial
investigation?

Blood gases (arterial or venous)


→ check pH and bicarbonate levels to diagnose
DKA
Criteria for DKA:
● Capillary blood glucose >11 mmol/L or known
history of diabetes
● Urine ketones level >+2 or capillary glucose >2
mmol/L
● Blood gases → pH <7.3 and/or bicarbonate <15
mmol/L
PLABABLE
Hypoglycaemia

44 year old man collapsed in


park and brought by the police +
he smells of alcohol + GCS is 14
+ capillary blood glucose level is
1.5 + there is no IV access and
medical staff is struggling to get
IV access

What is the single most appropriate


management?

Oral glucose gel

As he is conscious and aware, his


hypoglycaemia can be resolved with oral
glucose gel

Do not pick IM glucagon for this case

PLABABLE
Hypoglycaemia

47 year old diabetic man found


unconscious + paramedics are
unable to arouse him + capillary
blood glucose is 1.2 + profusely
sweating + starts seizing + there
is no intravenous access

What is the single most appropriate


management?

IM glucagon 1mg

As this patient is seizing, it is not appropriate to


gain IV access

PLABABLE
Hypoglycaemia

20 year old found unconscious +


smells of alcohol + paramedics
are unable to arouse him +
capillary blood glucose is 1.2 +
there is no intravenous access

What is the single most appropriate


management?

Insert IV line and administer 75 ml of 20%


glucose intravenously

Remember, glucagon is ineffective in


alcohol-related hypoglycaemia

PLABABLE
Bloating

21 year old man + abdominal


pain over last 8 months + mucus
in stools + abdominal bloating +
bloating and pain worsened after
a meal and relieved by
defecation + no weight loss

What is the single most likely diagnosis?

Irritable bowel syndrome

Abdominal bloating + pain + worse during eating +


relieved by defecation + passage of mucus →
Part of the diagnostic criteria of IBS

PLABABLE
Asthma

21 year old with acute shortness


of breath and wheezing + history
of asthma on inhalers + has been
taking more salbutamol over last
2 days + sPO2 is 93% + unable to
finish a sentence

What is the single most appropriate test to be


performed to determine the severity of his
asthma exacerbation?

Peak expiratory flow rate using peak flow meter

Moderate asthma exacerbation → PEFR 50-75%


Acute severe asthma → PEFR 33-50%
Life-threatening asthma → PEFR <33%

PLABABLE
Carbon Monoxide Poisoning

25 year old heroin addict


unconscious found next to a gas
stove in the kitchen which is
turned on. His pupils are dilated.

What is the single most appropriate


management?

Oxygen

The history of heroin is just a distractor. Heroin


causes pupil constriction. Those who are
unfamiliar with this may go on to choose options
like naloxone because of the heroin history.

PLABABLE
Cough

50 year old man with coughing +


shortness of breath + fever + pleuritic
chest pain for 3 weeks + ECG is normal
+ chest X-ray shows blunting of CP
angles

What is the most likely diagnosis?

Parapneumonic effusion

Parapneumonic effusion → Pleural effusion


adjacent to pneumonia

PLABABLE
Asthma

20 year old with wheezing + occasional


shortness of breath + asthmatic on
salbutamol and low dose inhaled
steroids + uses salbutamol 6-7
times/day

What is the next medication to add according to


BTS/SIGN asthma guidelines?

Salmeterol inhalers

Salmeterol is a LABA

PLABABLE
Haemoptysis

40 year old with haemoptysis for 1


month + sinusitis + bloody discharge
from nose + saddle nose deformity

What is the most likely diagnosis?

Granulomatosis with polyangiitis


(Wegener’s granulomatosis)

Components of disease
Nasal ● Saddle nose deformity
● Sinusitis
● Bloody rhinorrhoea
Lower ● Haemoptysis
respiratory
Kidney ● Haematuria
Skin ● Subcutaneous nodules
● Purpura

PLABABLE
Urinary Leakage

60 year old with continuous leakage of


small amount of urine vaginally + not
worsened by cough + history of
radiotherapy for cervical cancer

What is the most likely diagnosis?

Vesicovaginal fistula

Radiation to pelvis is one


of the risk factors for VVF

PLABABLE
Tiredness

30 year old man admitted with


nausea + vomiting + abdominal
pain + malaise for 2 months +
currently on salbutamol,
salmeterol and fluticasone for
asthma + hyponatremia +
hyperkalaemia

What is the most appropriate investigation to


confirm the diagnosis?

Short ACTH stimulation test

Malaise + hyponatraemia + hyperkalaemia is


highly suggestive for addisonian crisis

Synacthen test (short ACTH stimulation test) can


be used to confirm the diagnosis

PLABABLE
Hyperthyroidism

29 year old + 25 weeks pregnant


+ diagnosed with
hyperthyroidism + Thyroid
peroxidase positive + heart rate
is 110 beats/minute

What is the single most appropriate treatment?

Carbimazole

In pregnancy:
● 1st trimester → Propylthiouracil
● 2nd/3rd trimester → Switch to carbimazole

If carbimazole is not in the options, then


prescribe propylthiouracil

PLABABLE
Breast Discharge

21 year old woman + milk


secretion from nipples for 2
months + LMP was 6 months ago
+ Urine pregnancy test is
negative + no masses in her
breasts

What is the single most appropriate


investigation?

Prolactin levels

Galactorrhoea + amenorrhoea → Prolactinoma

PLABABLE
Diabetes

20 year old woman + tiredness +


weight loss + polyuria +
polydipsia + BMI is 19 kg/m² +
family history of diabetes
mellitus + HbA1c of 65 mmol/mol
+ no ketonuria

What is the single most appropriate next step in


management?

Genetic counselling for MODY

MODY → <25 years old + low BMI + family


history of DM

Refer for genetic counselling before genetic


testing
LADA → Consider in patients 30 to 50 years old

PLABABLE
Polyuria

31 year old man with polydipsia


and polyuria + hypernatraemia

What is the most likely diagnosis?

Diabetes insipidus

What is the single most appropriate initial test?

Urine osmolality

Polyuria + polydipsia + hypernatraemia →


Diabetes insipidus

Initial test → Urine osmolality

If urine osmolality < 800 mOsm/kg → Fluid


deprivation test

PLABABLE
Hypothyroidism

44 year old with tiredness + TSH is


high (12.8 mU/L) + normal free T4
(11 pmol/L)

What is the most likely diagnosis?

Subclinical hypothyroidism

What is the single most appropriate next step?

Repeat TSH in 3 months

Do not start treatment in subclinical


hypothyroidism

Further action will be decided after repeat test in


3 months

PLABABLE
PEG Tube Care

75 year old man + PEG inserted 1 day


back due to a stroke + one episode of
leaking of minimal gastric fluid + no
abdominal pain/bloating/skin irritation +
no discharge at PEG site

What is the single most appropriate


management?

Reassure and continue enteral feeding

PLABABLE
Urinary Tract Infection

49 year old woman + history of 5


urinary tract infections + confirmed
to be E. coli + regular menstrual
cycles + not sexually active + USG
and cystoscopy are normal

What is the most appropriate management?

Long term antibiotic prophylaxis

For recurrent UTI in premenopausal woman


prescribe long term antibiotics once underlying
causes have been ruled out

PLABABLE
Urinary Tract Infection

58 year old woman + history of 4


urinary tract infections + confirmed
to be E. coli + no haematuria +
menstruation stopped at 51 years +
not sexually active + USG and
cystoscopy are normal + no
postmenopausal bleeding

What is the most appropriate next management?

Vaginal oestrogen

Recurrent urinary tract infections in


postmenopausal woman + underlying causes
ruled out

→ Consider prescribing vaginal oestrogen


before long term antibiotic prophylaxis

PLABABLE
Hyperglycaemia

49 year old man + fasting blood


glucose of 7.7 mmol/L + no
symptoms of diabetes

What is the next step for diagnosing T2DM?

Repeat fasting blood glucose

Diagnosis of diabetes in asymptomatic patients


should be made only after 2 tests

If this patient was symptomatic, only 1 test is


needed to diagnose diabetes

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Diabetes

41 year old man + history of


diabetes currently on metformin
+ BMI of 33 kg/mL² + hbA1c is 58
mmol/mol

What is the next most appropriate step?

Reinforce lifestyle changes

It is appropriate to reinforce lifestyle changes


and add a new medication in this case. But, if
the candidate has to pick between lifestyle
changes and adding a new drug, the most
appropriate step is to select lifestyle changes

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Hyperparathyroidism

59 year old with constipation + fatigue + body


aches + history of renal colic and colles
fracture + high corrected calcium + high
parathyroid hormone levels

What is the most likely diagnosis?

Primary hyperparathyroidism

What is the single most appropriate


management?

Parathyroidectomy

Cinaclet is reserved for patients unsuitable for


surgery

Bisphosphonates may be used for preventing


fractures, but should not be used for chronic
hypercalcaemia with 1° hyperparathyroidism

PLABABLE
Urinary Tract Infection

32 year old woman with dysuria + 11 weeks


pregnant + urine dipstick shows +1 nitrates
and +1 leukocytes + urine culture sent

What is the most likely diagnosis?

UTI

What is the most appropriate treatment?

Nitrofurantoin

● 1st line (Early pregnancy)


→ Pick nitrofurantoin

● If nitrofurantoin is not an option


→ Pick cefalexin

● If nitrofurantoin/cefalexin are not options


→ Pick amoxicillin
PLABABLE
Urinary Tract Infection

5 year old + recently treated for UTI 4


weeks back + history of 3 UTIs in the past
year + currently asymptomatic

What is the single most appropriate investigation?

Ultrasound scan
In children >3 years old →

● 1st → Ultrasound scan. It is normal in this


case
● 2nd → DMSA scan to look for renal scarring.
Performed 4-6 months after infection

Remember not to pick MCUG. Use this


mnemonic to remember:

“M.C.U.Gee
Never pick over three!”

PLABABLE
Urinary Tract Infections

5 year old + recently treated for UTI +


history of 4 UTIs in the past year + USG
has been done and is normal

What is the single most


appropriate next investigation?

DMSA scan
In children >3 years old →

● 1st → Ultrasound scan. It is normal in this


case
● 2nd → DMSA scan to look for renal scarring.
Performed 4-6 months after infection

Remember not to pick MCUG. Use this


mnemonic to remember:

“M.C.U.Gee
Never pick over three!”

PLABABLE
Ulcers

70 year old man + ulcer above his


right medial malleolus + weak
dorsalis pedis and posterior tibial
pulses on both feet + haemosiderin
deposits around the ulcer + history
of diabetes mellitus + mild pain at
ulcer

What is the most likely diagnosis?

Venous ulcer

Ulcers at medial malleolus + haemosiderin


deposits → Venous ulcers

Neuropathic ulcers → Reduced sensation on


toes or sole of foot.

Arterial ulcers → Lateral malleolus. Would not


have haemosiderin deposits.

PLABABLE
Haematuria

65 year old man + 5 episodes of frank


painless haematuria + smooth enlarged
prostate + PSA is 2.9 ng/ml (0-4)

What is the most appropriate test to request?

Cystourethroscopy

>40 years old with frank haematuria →


Bladder cancer must be investigated →
Cystoscopy

Remember, cystourethroscopy is synonymous


with cystoscopy

PLABABLE
Osteoporosis

80 year old lady + recent fracture


T-score of -2.6

Most likely diagnosis → Osteoporosis

Which drug would be given to prevent


fractures after osteoporosis is diagnosed?

Bisphosphonates

T-score less than -2.5 is an indication to


begin bisphosphonate therapy

Supplements like calcium and vitamin D may


be added if dietary intake is inadequate

PLABABLE
Benign Prostatic Hyperplasia

50 year old man + voiding difficulties +


incomplete evacuation of bladder +
increased frequency + urgency +
smooth enlarged prostate

What is the best medication to start?

Tamsulosin

Do not pick finasteride as the first line treatment


option as it takes around 6 months to become
effective

PLABABLE
Haematuria

55 year old man with intermittent frank


haematuria + no fever or dysuria +
booked for cystoscopy + urine cytology

What is the most appropriate additional


investigation to request in this appointment?

CT urogram

>40 year old with frank haematuria should


undergo:

● Cystoscopy → To look for bladder cancer


● CT urogram → To look for renal and
ureteric cancers
● Urine cytology → To pick up cancer cells

PLABABLE
MORE COMING SOON

This is one of our NEW categories. So it does not


have many cards yet. But we will soon fill this up! Do
provide us feedback if we are on the right track!

PLABABLE
Image Attributions

https://commons.wikimedia.org/wiki/File:Xanthelasma.jpg
Klaus D. Peter, Gummersbach, Germany
CC BY 3.0 DE

https://commons.wikimedia.org/wiki/File:Cataract_(28464844371).png
National Eye Institute, National Institutes of Health
Public Domain

PLABABLE

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