A 75 year old woman has sudden onset left-sided chest pain and breathlessness for 1 hour on the orthopaedic ward. She also had one episode of haemoptysis. She had a total hip replacement 3 days ago. Her temperature is 37.2°C, pulse rate 100 bpm, BP 132/78 mmHg, respiratory rate 22 breaths per minute and oxygen saturation 92% breathing air. Chest examination is normal. Which is the most appropriate diagnostic investigation?

Correct Answer: C

Rationale: The most appropriate diagnostic investigation in this scenario is a CT pulmonary angiogram (Option C) to rule out pulmonary embolism. Given the patient's sudden onset of chest pain and breathlessness post-operatively, along with haemoptysis and normal chest examination findings, there is a high suspicion for pulmonary embolism. A CT pulmonary angiogram is the gold standard for diagnosing pulmonary embolism due to its high sensitivity and specificity. Arterial blood gases (Option A) may be useful in assessing oxygenation and ventilation status, but in this case, the clinical presentation points more towards a possible pulmonary embolism. A chest X-ray (Option B) may not show definitive findings for pulmonary embolism and is not the recommended initial diagnostic test. D-dimer (Option D) is a screening test for thrombotic disorders but lacks specificity; a positive result would necessitate further testing like a CT pulmonary angiogram to confirm the diagnosis. In an educational context, understanding the rationale behind choosing the most appropriate diagnostic test based on the clinical presentation is crucial for medical professionals to provide timely and accurate patient care, especially in emergent situations like suspected pulmonary embolism. The ability to differentiate between various diagnostic options based on clinical clues is a key skill for healthcare providers in managing psychiatric emergencies effectively.

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.

Correct Answer: D

Rationale: In this scenario, the most likely diagnosis for a 74-year-old man presenting with a sudden severe headache and mild left-sided weakness in the Emergency Department is meningitis (Option D). Meningitis is an infection or inflammation of the meninges, the protective membranes covering the brain and spinal cord. The symptom of severe headache, along with focal neurological deficits like left-sided weakness, raises concern for meningitis as it can lead to neurological complications. Option A, benign intracranial hypertension, is less likely as it typically presents with symptoms like chronic headaches, vision changes, and papilledema, rather than sudden onset severe headaches and focal neurological deficits. Option B, brain tumor, may present with headaches and focal neurological deficits, but sudden onset severe headaches are more indicative of an acute condition like meningitis rather than a chronic condition like a brain tumor. Option C, encephalitis, is characterized by inflammation of the brain tissue and can present with neurological symptoms similar to meningitis. However, the sudden onset severe headache is more commonly associated with meningitis, making it a more likely diagnosis in this case. Educationally, understanding the distinguishing features of different neurological conditions is crucial for healthcare providers, especially in an emergency setting. Recognizing the specific symptoms and signs of conditions like meningitis, brain tumors, and encephalitis can aid in timely diagnosis and appropriate management, ultimately improving patient outcomes.