1

Question 1

Farmer has 24 hour symptoms. Vital signs very bad hypotensive tachycardic and high resps, painful lymphadenopathy up right arm and paronchia of right thumb.
Orf, staphylococcal toxic shock syndrome, brucellosis

Answer 1

Orf

Question 2

Man has 4 month sx of pain in heel which has stopped him walking. An XR demonstrates a Calcaneal spur.

Answer 2

Plantar fasciitis
Calcaneal spur (or heel spur) is a bony outgrowth from the calcaneal tuberosity (heel bone) Plantar fasciitis is a common cause of calcaneal spurs. People who are obese, have flat feet, or who often wear high-heeled shoes are most susceptible to heel spurs.

Question 3

According to NICE guidelines, a patient has a Qrisk of 20%. What Rx?

Answer 3

Atrovastatin 20mg OD: 10 year mortality Qrisk score > 10% -> Give statins

Statins should be taken at night as this is when the majority of cholesterol synthesis takes place.

Question 4

A pt is informed that as per qrisk2 score, reduces risk heart disease 20%. How many patients like this would need a rx to save one person the bad CV event?

Answer 4

20

Question 5

true positives
/
true positives + false negatives

Answer 5

sensitivity: ability to detect those with the disease

Specificity: ability to correctly identify those without the disease
TN/(TN+FP)

Question 6

ECG with ST depression in v2-4. Which part of heart has been damaged

Answer 6

Posterior MI: usually left circumflex, also right coronary

Question 7

Patient has sudden onset L facial weakness and R arm weakness. They have diplopia on L lateral gaze.
Answers: L cerebral, L brainstem, R cerebral, R brainstem, MLF.

Answer 7

L brainstem
(Lateral medullary syndrome= L Brainstem)

Question 8

Long chat about a guy with bradycardia. His ECG shows broad QRS complexes 40bpm regular and p waves at a rate of 75bpm. Is this 1st degree, 2nd or complete heart block.

Answer 8

Complete heart block

Question 9

Pancreatitis guy gets v unwell with bibasal crackles his CXR is shown. What is dx

Answer 9

ARDS

Question 10

CSF Glucose was 4.4 (2-4.4), opening pressure 80cm H20 (normal), lots of white cells.

Answer 10

Viral

Question 11

HIV guy has brain MRI shows multiple ring enhancing lesions

Answer 11

Toxoplasma: 1st line prophylactic pyrimethamine + sulfadiazine + calcium folinate

Question 12

AIDS pt has disseminated infection with chest, abdominal pain, diarheoa, vomiting etc. He is then treated with multiple drugs, which is most likely organism.

Answer 12

Mycobacterium avium-intracellulare

Question 13

Patient with hypokalemia and hyponatremia. What is best Ix

Answer 13

Aldosterone and Plasma Renin Activity.

Question 14

Cluster headache acute rx: triptans, O2, verapamil

Answer 14

O2

Question 15

Description woman with dry eyes (Sjogen) what is rx?

Answers: Prednisolone, hypromellose artificial tears,

Answer 15

Rx - Artificial tears, Saliva replacement solutions, NSAIDs and hydroxychloroquine for arthralgia, Immunosuppression for severe systemic disease

Question 16

Black guy lower 7th same pic as 5th year. Pic shows its lower coz eyebrow also weak. Next test

Answer 16

Examine ear – Infectious causes of facial nerve palsy -> VZV reactivation (RH syndrome), Otitis Media, Malignant otitis externa

Question 17

Menieres description ie dizzy deaf and vertigo with ear fullness next Ix?
MRI inner ear, Audiometry

Answer 17

Audiometry

Question 18

Weber lateralises to L ear, Rinne’s positive on the R (AC>BC)

Answer 18

Acoustic neuroma

Question 19

Hearing loss, has FHx, worsen in preg

Answer 19

Otosclerosis

Question 20

Ghanian girl 20yo collapses during badminton. O/E has pansystolic murmur mitral region (MR) and ejection systolic murmur (AS) and father had sudden death

Answer 20

HOCM

Question 21

Patient with HF has found hypokalameia 2, what is cause

Answer 21

Metolazone

Question 22

Patient has coarse crackles lower lobe. Describes CAP Whats commonest

Answer 22

Strep pneumo

Question 23

Classic patient has pink urine. He had a URTI 3 days ago.

IgA nephropathy, Post strep

Answer 23

IgA nephropathy,

Question 24

Heavy smoker has cavitating lesion at L hilum. Bronchoscopy reveals a lesion with Keratin pearl.
Squamous Cell Carcinoma, Adenocarcinoma, small cell carcinoma

Answer 24

Squamous Cell Carcinoma

Question 25

Squamous Cell Carcinoma what is next tx

Answer 25

Surgery – unless mets -> Chemo/Radiotherapy

Question 26

Old person has post prandial pain and pr clear

Answer 26

mesenteric ischemia

Question 27

Classic stable angina but asthma

Answer 27

Calcium Channel Blocker,

Question 28

Prolong survival HF

Answer 28

Spironolactone

Question 29

Calcified heart on CXR kussmaul sign. | Tamponade, constrictive pericarditis, TB pericarditis

Answer 29

constrictive pericarditis

Question 30

Woman has had headache and been at home a week. Is found unresponsive by neighbour. Her pulse 56, BP 166/86 and fast followed by slow breathing. Cause?

Answer 30

raised ICP

Question 31

Supports a diagnosis of shy dragger? (type of MSA) | Orthostatic hypotension, atypical tremor, aphasia

Answer 31

Orthostatic hypotension

Question 32

Pt has nonspecific sx nausea malaise etc and yellow tinge on white objects (Xanthochromia)

Answer 32

Digoxin

Question 33

Pt has yellow tinge to scan after treated for infection why?

Answer 33

Coamoxiclav

Question 34

long description of obvious pancreatic cancer first ix | Endoscopic Us, CT, AXR, Abdominal US

Answer 34

``` Abdominal US (also would do pancreas specific CT and LFTs 1st line ```

Question 35

CT scan demonstrated huge renal cancer on R side. Biopsy shows which most likely histology?

Answer 35

Clear cell

Question 36

Patient has huge ortho op and medullary nail for hip fracture. Next day comes in hugely unwell

Answer 36

fat embolism - Hypoxia + Neuro impairment + Petechai

Question 37

GCS c. 5 What do you do? | Cuffed tracheal tube, laryngeal mask, tracheostomy

Answer 37

Cuffed tracheal tube

Question 38

Pt has fit and you as doctor are told by patient he adamant will not tell DVLA. 1) Professional duty not legal to breach confidentiality, 2) legal duty to breach if in pts best interests

Answer 38

Professional duty not legal to breach confidentiality

Question 39

Hypercalcaemia of malignancy 2 qns one in each paper. First was whats most important initial IV rx? 9% saline, Bisphosphonates

Answer 39

9% saline

Question 40

what drug to use in hypercalcaemia: IV zoledronate (bisphosphonates), Furosemide

Answer 40

IV zoledronate

Question 41

Neutropenic sepsis whats most likely org

Answer 41

e coli (previously -> now gram +ve cocci eg Staph, Strep)

Question 42

Unknown Overdose during argument in a guy recently prescribed antidepressants- which drug. PT was 48, ast 64 (would expect in 1000s and think was an OD after 24 hours). no info pupils: flumazenil, tricyclic, fluoxetine, paracetamol, Aspirin

Answer 42

Aspirin

Question 43

2 years ago displaced fracture talus in accident. Now 2 yr later pain - xr shows sclerotic area middle of bone

Answer 43

AVN

Question 44

Diabetic with ascending weakness. Weird power of how 4/5 and 3/5 mostly in arms and legs. can't close eyelids properly, reflexes gone planters absent but sensation fine – Gullian barre, DM, MG, MS.

Answer 44

Gullian barre (variant of GBS -> Miller Fisher syndrome… Ascending weakness + ATAXIA + OPHTHALMOPLEGIA + AREFLEXIA)

Question 45

Pt has diplopia on R gaze

Answer 45

R abducent palsy

Question 46

Disseminated renal cell. Progressive pitting oedema legs and distended abdo veins Hypoalbuminaemia, inginal lymph nodes blocked, IVCO

Answer 46

IVCO

Question 47

Guy has lots lesions with rough skin on bald forehead. This lesion predisposes to what?

Answer 47

SCC

Question 48

Guy on clozapine for schizophrenia and ivdu comes in. o/e neck stiffness, moving all limbs, t39.8 13/15 gcs. bact mening, abscesses, NMS, SS

Answer 48

NMS Common to both: - drug reaction - often young patients - tachycardia, raised BP - pyrexia, diaphoresis - rigidity - IV fluids and benzos tx Serotonin syndrome: - Caused by SSRIs, MAOIs, ecstasy/novel psychoactve stimulants - faster onset (hours0 - increased reflexes, clonus, dilate dpupils - mx severe cases: cyproheptadine, chlopromazine NMS: - Caused by antipsychotics - slower onset (hours-days) - decreased reflexes, 'lead-pipe' rigidity - normal pupils - Mx of severe cases: dantrolene

Question 49

Diabetic with bad kidney function gfr low, creatinine>150. What drug to start after diet? metformin, gliclazide

Answer 49

Glicazide

Question 50

Guy painful retention and u+e off - USs shows vv distended bladder. Uro referral, catheter

Answer 50

catheter

Question 51

Single marker prognosis in Hodgkin? | crp esr albumin

Answer 51

albumin

Question 52

Hoarse voice weak cough post thyroidectomy | neurpraxia of recurrent largyneal, laryngeal oedema, heamatoma

Answer 52

Neurpraxia of recurrent largyneal

Question 53

Patient with papules pustules, telangiectasia, red flushing on face

Answer 53

Rosacea

Question 54

In a new trial, why does orally administered drug have lower area under curve than iv?

Answer 54

First pass hep metabolism: The drug is absorbed from the GI tract and passes via the portal vein into the liver where some drugs are metabolised. Sometimes the result of first pass metabolism means that only a proportion of the drug reaches the circulation Alternative routes of administration like suppository, intravenous, intramuscular, inhalational aerosol, transdermal, buccal and sublingual avoid the first-pass effect because they allow drugs to be absorbed directly into the systemic circulation.

Question 55

In RCT, if there is a large nocebo effect, what does this mean?

Answer 55

unblinding has occurred: Nocebo effect = negative expectations of the patient regarding a treatment cause the treatment to have a more negative effect than it otherwise would have. Eg anticipating side effects of a medication -> ptn suffers that effect even if the "medication" is actually an inert substance

Question 56

Woman has breast lump removed for which the pathologist provides their standard report. For which of these in further investigation needed? Grade, stage, ER status, completeness of excision.

Answer 56

completeness of excision

Question 57

Death certificate easy pt has RLL crackles after being admitted. Rx but dies next day whats 1a?

Answer 57

Part 1 = Cause of death Part 2 = Conditions that contributed to death/made patient weaker eg. IHD (2) -> Pneumonia (1a)

Question 58

Anxious banker worried about work palpitations at night. What u do as GP

Answer 58

arrange ecg, confident it's not arrhythmia but can't be sure

Question 59

proteinuria and oedema. what's most likely cause

Answer 59

Focal segmental now more common than membranous in adults

Question 60

CML treatment

Answer 60

Imatinib inhibitor of the tyrosine kinase associated with the BCR-ABL defect very high response rate in chronic phase CML

Question 61

Guy hit from behind car accident, immediate pain shoulder neck and spasm muscles. Ix and exam all normal at first, but still pain at 4 weeks despite normal XR and exam , next ix? Mri or refer neuro

Answer 61

MRI - check for other injuries

Question 62

Man has pickled beetroot he made few days ago and some weakness in face (non specific, would expect multiple palsies):

Answer 62

clostridium botulinum

Question 63

Kid has muscular hypertrophy amd struggling to run with kids 3 years. He has huge calves. Where is the problem? Anterior horns cells, peripheral, striated muscle

Answer 63

striated muscle - muscular dystrophy - problem in dystrophin a protein in the cytoskeleton

Question 64

A young guy has just come back from a 3 month trip in the south of Africa and has had 2 weeks of frank hematuria. A urine dipstick demonstrates 3+ myoglobin. Which is likely cause? Schistosomiasis, strongyloides.

Answer 64

Schistosomiasis

Question 65

Schistosomiasis next investigation

Answer 65

Terminal urine microscopy

Question 66

Patient has treatment for RA and then gets extensive and widespread TB, what is likely cause?

Answer 66

Infliximab – immunosuppression reactivates TB… Primary -> Latent -> (Reactivated) Secondar

Question 67

Pt has had injury to leg and had morphine but in anguish, what next rx? Increase morphine, ignore because patient is druggie, refer to surgeons for fasciotomy

Answer 67

refer to surgeons for fasciotomy

Question 68

Teratoma tumour marker

Answer 68

AFP (also markers for HCC)

Question 69

Lady with 1 episode of PMB, O/e atrophic vaginitis (common cause of PMB) description of pink raw genital skin, her TV USS shows endometrial thickness 3mm. rx?

Answer 69

AV Mx: Vaginal lubricants, Topical oestrogen cream PMB -> 2ww TVUS to assess endometrial thickness If endometrial thickness >4mm -> pipelle biopsy to assess for endometrial hyperplasia or cancer

Question 70

105. Pt after RTA 1g IV paractemeol but still in pain, next rx?

Answer 70

Para -> NSAID -> Weak opioid (codeine) -> strong opioid (morphine or pethidine – caution in RF) Neuropthic pain: National Institute of Clinical Excellence (UK) guidelines: * First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin * Second line: Amitriptyline AND pregabalin * Third line: refer to pain specialist. Give tramadol in the interim (avoid morphine) * If diabetic neuropathic pain: Duloxetin

Question 71

Woman 30yo who has been in UK 8 years , originally from brazil. Has pain, tingling, sensory loss all limbs v weird no obvious pattern. Has thickened ulnar and peroneal nerves. Answer likely Leprosy therefore rx is

Answer 71

dapsone, rifampicin, and clofazimine.

Question 72

Description of diabetic gastroparesis (vagus neuropathy -> gastroparesis slows) young T1DM ha dyspepsia and nausea after meals what is best rx -

Answer 72

Stimulate stomach muscles: Metoclopramide, Domperidone and Erythromycin (other anti-emetics to control nausea

Question 73

25yo from Bangladesh 2 week ago gram negative rods were grown in aerobic and anaerobic bottles, had rash buttocks thighs (rose spots – patchy red macules). which organism?

Answer 73

salmonella typhi/paratyphi – also look for a relative bradycardia

Question 74

Post splenectomy most likely strep pneumo. One person told me that qn said pt was on prophylactic penicillin V, which is most likely org. If it says that then answer is

Answer 74

haemophilus influenza

Question 75

Contrast CT showing focal bilateral temporal involvement: | This patient had prolonged seizure then died

Answer 75

HSV encephalitis

Question 76

Guy has transjugular shunt, and next day noted to be solmnent. Why?

Answer 76

TIPS predisposes to hepatic encephalopathy because ammonia can reach brain and cause osmotic change, damaging astrocytes

Question 77

Wasted small muscles hand, abduction adduction and thumb adduction all weak. Loss of sensation of medial aspect of forearm . Triceps biceps reflexes and finger flex normal. L arm normal

Answer 77

T1 or c8 lesion

Question 78

Guy who plays golf with pain at lateral epicondyle (of humerus) what muscles weak?

Answer 78

Radial nerve affected - extensors wrist (ie muscles on ventral aspect of forearm)

Question 79

Description of asthma lady who has exacerbations despite SABA LABA and ICS at maximum dose, what next? PO pred, or leukotriene receptor antagonist,

Answer 79

leukotriene receptor antagonist: 1) SABA 2) +ICS 3) LABA +ICS or trial or LTRA/theophilline/LAMA 4) high dose ICS or trials above adding 4th drug 5) oral steroid

Question 80

Lady with UC, has been well controlled for 3 years with mesalazine, now admitted with severe 8 bloody stools/d , - increase po mesalazaine, give po pred or iv hydrocortisone

Answer 80

iv hydrocortisone

Question 81

Guy dysuria for 4 days and 4 raised painful lesions on corona of penis

Answer 81

herpes simplex

Question 82

How does sildanefil cause postural hypotension

Answer 82

PDEV inhibitor resulting in vasodilation

Question 83

Ground glass hepatocytes: aa1 low levels, Wilsons, hepatitis B

Answer 83

hepatitis B

Question 84

A man has polycythaemia which is well treated. He then moves practice area and represents 2 years later with distended abdomen and dilated abdominal veins. Portal vein, splenic vein thrombosis

Answer 84

Polycythaemia Rubra Vera which causes Budd Chiari = HEPATIC vein thrombosis * Primary BCS: PRV, Pregnancy, OCP, HCC, Lupus anticoagulants * Secondary BCS: Compression by external structure eg. tumour

Question 85

painful knee t 38.5. Start empirical abx or urgent aspirate and ix fluid?

Answer 85

urgent aspirate

Question 86

Guy tired all time normal t4 7, tsh <0.01, testosterone also low 0.02

Answer 86

hypopituitarism

Question 87

Man has painful face and headache with no cause found. He represents a few days later with a few red bumps which extend past the orbit to midline, what is like nerve affected?

Answer 87

Trigeminal opthalmic branch: herpes zoster ophthalmicus

Question 88

Guy with HIV has culture with silver stain which is positive, organism?

Answer 88

Aspergillus, Pseudomonas, Legionella, Pneumocystis, Cryptococcus, Candida all silver +ve

Question 89

Ix for pulseless cold R leg?

Answer 89

Ix = Doppler US (both limbs) +/- CT angiography (esp if limb salvageable, gather more info) profound paralysis with complete lack of sensation or fixed mottling = unsalavagable

Question 90

guy punched someone 3 days ago. Oe cut on 3rd knuckle and exquisitely tender on palmar aspect and can't move passively.

Answer 90

surgical debridement and iv abx w

Question 91

LMN 7 palsy presents at 48hr, what rx is indicated

Answer 91

Tx LMN CNVII with prednisolone within 72hrs, + Valaciclovir if VZV

Question 92

Guy during flexible cystoscopy becomes unresponsive and HR 38 bradycardic. 1st rx?

Answer 92

atropine

Question 93

Guy has COPD, which spirometer value high will be high?

Answer 93

Hyperexpanded: HIGH TLC and Residual Vol FEV1 <80% FEV1:FVC <0.7

Question 94

V myopic (near-sighted) person sudden loss vision curtain in eye

Answer 94

Retinal detachment (NB myopia major rf for development of RD)

Question 95

Someone addisonian. Descrption was electrolytes show low Na, high K, has postural drop in BP of like 20/10, and looks unwell. What is best rx?

Answer 95

100mg hydrocortisone

Question 96

9am cortisol low what's best dx for addisons?

Answer 96

24 hr cortisol urine (used in Cushings – see loss of diurnal variation with increased midnight cortisol) or Addisons Ix: 9am cortisol (LOW), 9am ACTH (HIGH) Synacthen test (cortisol doesn’t rise

Question 97

Guy had UTI and was treated with Abx. At review appointment, cr 430 and k high most likely dx?

Answer 97

ckd likely undetected – Trimethoprim in CKD ptn -> Raised Cr and K

Question 98

Pt is pen allergic, what drug can u give? | Teicoplanin, cephalosporin, meropenem, tazocin and co-amoxiclav

Answer 98

Teicoplanin (glycopeptide - same as vancomycin)

Question 99

Person has CAP and has sugar 8. Checked 6 weeks later 5 fasting and 7 ogtt why was it higher during the CAP?

Answer 99

Stress hyperglycaemia

Question 100

Old woman with osteoporosis has severe pain trying to lift shopping bag first ix?

Answer 100

Plain xr

Question 101

Pt having a GI bleed is peripherally ‘shut down’ and it is decided to cannulate his subclavian vein, what is the most likely complication?

Answer 101

subclavian artery damage Carotid artery damage is actually more common if answer

Question 102

Pt admitted who is alcoholic, given 2 pictures of bad teeth and another of hair follicles with parafollicular haemorrhage, what is the likely deficiency?

Answer 102

vitamin C (Scurvy)

Question 103

What to give with tb drugs?

Answer 103

Pyridoxine (vitamin B6, otherwise will be depleted by isoniazid causing peripheral neuropathy)

Question 104

Metallica valve warfarinised but has taken erythromycin and INR now 9.1, presents with nosebleed. 10mg or 1mg vit k IV?

Answer 104

Major bleeding: 5mg IV Minor bleeding: 1-3mg IV No bleeding and INR>8 = 1-

Question 105

Pt on rchop chemo, why hyperglcaemia?

Answer 105

Prednisolone

Question 106

Young Pt on chemo, why’d he develop heart failure

Answer 106

Doxirubicin

Question 107

Pt rxed chemo obs on wr normal. 30 mins later fucked and after 3l resus doesn’t help her sats, what is likely pathogen?

Answer 107

staph aureus -> major cause of Neutropenic Sepsis (used to be EColi; more likely endogenous pathogen)

Question 108

Pt ra and spleen. Whats most likely finding on blood?

Answer 108

Neutropenia - Feltys

Question 109

Obv description of pt has UC. What is most likely histology? Villous atrophy, intraepithelial lymphocytes, superficial ulceration, crypt abscesses.

Answer 109

superficial ulceration

Question 110

Pt to be discharged. Their previous FBCs from past 3 days show a slowly correcting hyponatraemia, what do u recommend?

Answer 110

Hold fruseomide and see what happens

Question 111

Pt severe resp infection has na 119 and urinary na 70. Rx?

Answer 111

SIADH Mx: IV hypertonic saline (if severe) + Fluid restriction + Tx underlying cause + Furosemid (if acute) + Vasopressin-R antagonist (if chronic)

Question 112

Pic of vf loss right superior quadrantopia which lobe is lesion

Answer 112

Temporal – UPPER Quadrantanopia | Parietal – LOWER Quadrantanopia

Question 113

Rheumatic fever crp 300. Admitted. Whats cause, ie?

Answer 113

Streptococcus pyogenes

Question 114

Question about patient on medications for stress incontinence, what is likely cause of their confusion and retention?

Answer 114

Oxybutynin

Question 115

Patient has continuous urine leakage needed pads for 1 year, hx includes radiotherapy for cervical cancer, cause?

Answer 115

Vesicovaginal fitsula

Question 116

Woman 4 episodes hemoptysis all tests normal but cxr still shows this rounded peripheral lesion? Dx?

Answer 116

Cancer

Question 117

Guy has collapsed in football. Had undescended testis fixed at 4. Given CT chest with so many mets, most likely histology?

Answer 117

non-seminoma germ cell tumour

Question 118

Which of following is most specific sign of LVF? | S3 gallop, S4, ejection systolic murmur

Answer 118

S3 gallop