A 55 year old man has diarrhoea and weight loss for 9 months. He has an intensely itchy red rash on his buttocks and thighs. Investigations: Haemoglobin 108 g/L, Blood film: anisocytosis. Which is the most likely histological appearance on small bowel biopsy?

Correct Answer: D

Rationale: The correct answer is D) Ulceration. Explanation: In the given clinical scenario of chronic diarrhea, weight loss, anemia, and skin rash, with findings of anemia and anisocytosis on blood tests, the most likely histological appearance on small bowel biopsy would be ulceration. Ulceration is a common finding in conditions like Crohn's disease, celiac disease, or infectious enteritis, which can present with similar symptoms. Why the other options are wrong: A) Hyperplasia of Brunner's glands: This finding is associated with conditions like duodenal ulcers, not typically seen in the context described in the question. B) Increased intraepithelial macrophages: This finding is more suggestive of conditions like celiac disease or inflammatory bowel disease, which typically present with different clinical features. C) Increased lymphocytes in submucosa: This finding is more commonly associated with inflammatory conditions like celiac disease, rather than the chronic diarrhea and skin rash described in the question. Educational context: Understanding the histological appearance on small bowel biopsy is crucial in diagnosing various gastrointestinal conditions, especially in cases of chronic diarrhea and weight loss. This question highlights the importance of integrating clinical findings with histopathological features to arrive at an accurate diagnosis in patients with gastrointestinal symptoms.

Correct Answer: B

Rationale: The correct answer is B) Metabolic alkalosis. In this scenario, the infant's symptoms of vomiting, constant hunger, and weight loss suggest a condition known as pyloric stenosis, where there is obstruction at the outlet of the stomach, leading to persistent vomiting. This vomiting results in the loss of hydrochloric acid from the stomach, leading to metabolic alkalosis. Option A) Metabolic acidosis is incorrect because the symptoms do not suggest an excess of acid in the body. Option C) Normal acid/base state is incorrect because the symptoms clearly point towards an imbalance. Option D) Respiratory acidosis is incorrect as there are no signs of respiratory compromise in the scenario provided. Understanding acid-base imbalances is crucial in diagnosing and managing various medical conditions. In this case, recognizing the metabolic alkalosis associated with pyloric stenosis can guide appropriate interventions and treatment strategies, highlighting the importance of clinical correlation in pediatric emergencies. This knowledge is essential for healthcare providers, especially those working in emergency or pediatric settings, to ensure timely and accurate assessment and intervention in such critical situations.

Correct Answer: C

Rationale: In this scenario, the most likely diagnosis for the 6-year-old girl's itchy, red rash with yellow crusting on her face and neck is impetigo (Option C). Impetigo is a common bacterial skin infection that primarily affects children. The rash typically presents with honey-colored crusts on an erythematous base, matching the symptoms described. Option A, Chickenpox, typically presents with vesicular lesions in different stages of development and is less likely in this case based on the description provided. Option B, Fungal infection, would present differently, usually with raised, scaly borders and a central clearing. Option D, Measles, presents with a maculopapular rash that starts on the face and spreads downward over the body, not with localized crusting as described. In an educational context, understanding the characteristic presentations of common pediatric skin conditions is crucial for healthcare providers to accurately diagnose and treat patients. Recognizing the distinguishing features of impetigo helps in appropriate management, which may include topical or oral antibiotics. This case highlights the importance of clinical knowledge and observation skills in identifying skin conditions accurately in pediatric patients.

Correct Answer: A

Rationale: The correct answer is A) Drug side effect. In this case, the patient's use of amlodipine, a calcium channel blocker, is the most likely cause of his ankle swelling. Amlodipine is known to cause peripheral edema as a common side effect due to its vasodilatory properties. This type of swelling is often bilateral and symmetrical, as seen in this patient. Option B) Heart failure is less likely in this case as the patient's ankle swelling is more likely to be due to a drug side effect rather than a cardiac issue. Heart failure-related edema tends to be more generalized and may be associated with other symptoms like shortness of breath, fatigue, and a history of heart disease. Option C) Lymphoedema is less likely as it is usually a chronic condition characterized by localized swelling due to lymphatic system dysfunction. It is less likely to present acutely in a patient like this with a recent onset of ankle swelling. Option D) Nephrotic syndrome is less likely as it typically presents with other symptoms such as proteinuria, hypoalbuminemia, and hyperlipidemia. Ankle swelling in nephrotic syndrome is usually a result of fluid retention due to kidney dysfunction rather than a drug side effect. In an educational context, understanding the common side effects of medications is crucial for healthcare providers to effectively assess and manage patients. Recognizing drug-induced adverse effects, like peripheral edema from amlodipine, can help prevent misdiagnosis and ensure appropriate treatment. This case highlights the importance of considering medication-related causes of symptoms in clinical practice.

Correct Answer: D

Rationale: In this scenario, the most appropriate diagnostic investigation for the 75-year-old woman with episodes of dizziness followed by collapsing to the floor is option D) Echocardiogram. An echocardiogram is the most suitable test as it can help assess the structure and function of the heart, identify any abnormalities such as valvular disorders, cardiac arrhythmias, or structural issues that could be causing the episodes of dizziness and collapsing. In older individuals, cardiac issues are more common and can present with symptoms like dizziness and syncope. Option A) 24-hour blood pressure monitoring would be more relevant if there were suspicions of postural hypotension or hypertension causing the symptoms, but given the presentation of collapsing, an echocardiogram is more appropriate. Option B) 24-hour ECG monitoring would be useful for detecting cardiac arrhythmias, but it might not provide the structural information that an echocardiogram can offer. Option C) A standard ECG could show some cardiac abnormalities but may not be as comprehensive as an echocardiogram in evaluating the structural and functional aspects of the heart. In an educational context, understanding the appropriate diagnostic tests for different clinical scenarios is crucial in the management of patients, especially in psychiatric emergencies where medical conditions can often present with psychiatric symptoms. This question highlights the importance of considering cardiac causes in elderly patients presenting with syncope and dizziness, emphasizing the need for a comprehensive cardiovascular evaluation like an echocardiogram.